Wiki 20610 Aetna denying for experimental or investigational

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Gladdie

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I have gotten several denials from Aetna recently denying 20610 as investigational or experimental. The diagnosis codes being used are M17.11 and M17.12 osteoarthritis of the knee. We have been billing these codes for years and have been getting paid. I researched policies and could not find any relevant changes. I called Aetna and the rep told me to appeal with notes to establish medical necessity. I have sent one appeal but do not expect good results since this is the standard Aetna response to any investigational/experimental denial. I put the codes into Navinet and the combination of 20610 with M17.11/12 was allowable. I suspect the diagnosis code is the reason for the denial. Does anyone know if we have to use an acute code now with 20610 or have any advice. Thanks.
 
Code 20610 is not the problem or the issue

I'm sorry but to be honest your problem is AETNA itself. They also will deny degenerative meniscus tears as "experimental" and sight a study performed by internal medicine physicians and ignore others that show it is effective.

I'm sure you are billing 20610 with euflexxa or another visco supplementation product. Even though this has been shown to be effective, I'll bet that AETNA has changed their policy on euflexxa and other similar products.

I would appeal with medical records showing the patient's improvement after the injection. That's the only way AETNA is going to change their policy.
 
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If you are injecting a drug that Aetna is considering experimental then you cant bill Aetna for the administration of that drug.
 
AETNA is denying it in error

I had the same issue and was even getting inconsistent denials on claims for individuals patients, ie: euflexxa series that was provided by specialty pharmacy so we were only billing CPT 20610 w/DX M17.11; first injection paid, second denied, third paid. It took some leg work and long hold times with state side reps but I was told that AETNA denied these injections in error due to a system error. On 12/14/18 I was told their system was wrong and the injections were denied in error, dx is billable per policy 0673 their system wasn't updated w/this info, they did a mass adjustment project to reprocess the injections that were denied in error. My best advice is to call and get a state side rep on the phone, be relentless, demand something to support this since their policy supports what is being billed.
 
It could be the dx code you are using. if the drugs are for pain control then you may need a G89 code for acute or chronic pain listed first as the medical necessity and the M17.11 or M17.12 code as the secondary. I have found this to be very effective.
 
There is a system error with Aetna. It is NOT YOU ! Just call them and they will send back through for correction. It does amaze me that this has been going on so long and they can't get it "fixed."
 
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