Aetna Denial for 20611 as experimental

[kbritt77]

We are seeing Aetna denials for 20611 as experimental. No other payer has this denial. Has anyone had any luck with appealing these with Aetna or is this a true denial. Their policy for Aetna MA are pointing to a commercial policy

 

[amyjph]

What is being injected, where, and why?

Example: https://www.aetna.com/cpb/medical/data/100_199/0179.html

https://www.aetna.com/cpb/medical/data/900_999/0952.html

 

[flipflop40@verizon.net]

Code as 20610, 74962

 

[amyjph]

Code as 20610, 74962

This is incorrect advice. 76942 cannot be reported with 20610 since the new CPTs 20604, 20606, and 20611 were created about ten years ago.
There is a parenthetical at the end of the section which states, (Do not report 20610, 20611 in conjunction with 27369, 76942).
There is a typo where I think you meant 76942 but typed 74962.

If the op looks at the second policy link, this is why it is being denied. I assume it is a knee joint injection they are talking about. Depending on the drug, the fist link talks about Visco.
Aetna considers US guidance of no proven benefit for the following procedures (not an all-inclusive list):

• Knee joint (except in morbidly obese individuals (BMI > 40))

https://www.kzanow.com/coding-coaches/cpt-code-20610-or-20611