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AETNA denying coverage of ultrasounds
F2M n Spouse
Posts: 1,021 ✭✭
OB office called this morning stating Aetna won't cover the 20 week ultrasound and we will have to fork out several hundred to have one done. Needless to say we're LIVID!!!
For anyone who has Aetna do you know what "diagnosis" is needed to be billed to have the ultrasound covered? A rep told us that the only way the ultrasound will be covered is if it's billed under a covered medical diagnosis.
I don't know how the OB office doesn't know the ins and outs of our insurance when they only accept a few but they know Aetna gives them a hard time about covering ultrasounds.
For anyone who has Aetna do you know what "diagnosis" is needed to be billed to have the ultrasound covered? A rep told us that the only way the ultrasound will be covered is if it's billed under a covered medical diagnosis.
I don't know how the OB office doesn't know the ins and outs of our insurance when they only accept a few but they know Aetna gives them a hard time about covering ultrasounds.
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And in case it helps, the diagnosis code for a routine singleton pregnancy is Z33.1 in ICD-10 (I can't remember what it was in ICD-9 but I can find that out for you if you need it - this is part of what I do professionally).
I would call Aetna to find out why it was being denied. It may be something other than a wrong CPT code like a provider issue (the radiologist may be out of network) or that your plan requires pre-authorization.
Trying for Baby #2: 4th IUI June 2016 - BFP!
Sweet little Rose was born on Feb 25th
Baby #1: Lucky #7 July 2015 - BFP
Our little girl, Hope, was born at 20w4d after PPRoM. She passed away 2 hours after birth.
I am overweight and have high blood pressure and she wouldn't tell me exactly what the diagnoses needs to be to have coverage but that to go to Aetna.com and it will tell you. Well we did and the only thing I could find that would maybe get the ultrasound covered is being overweight and having high blood pressure. But it's a crab shoot since I don't know if definitively it will be covered or not since they're not going to run it until we show up for the ultrasound.
I know my OB is in network because I called Aetna to ask for OBs covered in our area and they gave me a list.
I also have Aetna and they have covered all of my ultrasounds. I would call to hound them for an answer regarding the coverage and exactly what CPT codes would be approved (likely it will be either 76805 or 76811 - though they already denied that one). Like everyone else said, it's a pain to get through to them but they usually respond to customers pushing them for answers. They should cover one detailed anatomy scan in a pregnancy.
Also, it might be worthwhile to double check your plan to see what coverage period is used (calendar year vs fiscal year). Depending on the type of plan you have and the coverage period it uses, you may be stuck paying into your annual deductible which could explain the response from the billing office (but that shouldn't be a flat out denial).
Trying for Baby #2: 4th IUI June 2016 - BFP!
Sweet little Rose was born on Feb 25th
Baby #1: Lucky #7 July 2015 - BFP
Our little girl, Hope, was born at 20w4d after PPRoM. She passed away 2 hours after birth.
They're trying to use either code 76817 or 76811 for the 20 week ultrasound to be covered. I have no idea what code they used for my 10+5 week ultrasound but I'm assuming it was covered because I was spotting prior to it and if there's spotting or threatened abortion it's covered. I had an ultrasound at 8 weeks and that was covered and 10+5 and I'm assuming that was covered because they didn't mention to me today that it wasn't.
I will call again tomorrow morning and hopefully get some better answers. But I don't know what codes were used for the two ultrasounds.
Charlese was born on June 17, 2017 at 8:33 AM. She was the most gorgeous baby I've ever seen. She came into this world weighing 7 lbs and 5ozs. She was 19 1/2 inches.
Will try for #2 around September 2019! I’m ready to complete my family!