Wiki 95165 and Aetna

[spencer267]

We have been getting denials from Aetna insurance when billing our 95165. They state you can only bill 120 units for 95165 in a 365 day period or 30 every 3 months. If we use our 120 units and still have serum to make and bill can we switch to billing 95125 even though their serum is specifically prepared for them and not drawn off the board?

 

[mitchellde]

If the payer states that coverage is limited to 120 units per 365 days then you cannot bill for more using a different code to make it appear as a different substance. You need to either request an exception for this patient or anything over the covered is patient responsibility

 

[spencer267]

The insurance won't allow us to bill the patient for the overage.

 

[mitchellde]

Then that is your answer. If you cannot bill the patient and they will not cover for more , you either give it for free or request an exception based on medical necessity.

 

[commitsvs]

Hello Spencer267,

Can you please share me the Aetna Insurance policy details, which state we can only bill 120 units for 95165 in a 365-day period or 30 every 3 months but found this for Allergy test but no information about serum mix.

Number: 0038
(Replaces CPB 326)

• 0038-Allergy Testing and Allergy Immunotherapy

Thank you.