Aetna denying pain management procedures

lcole7465

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I have a denial from Aetna for a pain management procedure. We billed 64635 & 64636 for RFA lumbar. Aetna is denying as payment is inclusive in payment for other procedure and procedure code incidental to primary procedure not submitted for adjudication. This is the primary procedure. The patient had the injections done prior to the RFA. This is the first RFA performed, so I'm not sure if a modifier would be needed.

Thanks
 
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I have a denial from Aetna for a pain management procedure. We billed 64635 & 64636 for RFA lumbar. Aetna is denying as payment is inclusive in payment for other procedure and procedure code incidental to primary procedure not submitted for adjudication. This is the primary procedure. The patient had the injections done prior to the RFA. This is the first RFA performed, so I'm not sure if a modifier would be needed.

Thanks

Were there any other surgeries or procedures done previously? Was any testing or evaluation done that determined the need for the RFA? Have you checked Aetna's policies to see if they require other interventions be attempted first?
 

lcole7465

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No surgery was done prior to the RFA. The patient had injections done more than 30 days prior by a different physician. I know that Medicare/Medicaid requires certain steps such as injections and such before approving the RFA's. So since this is not in a global period, I know that the -79 modifier would not correct.
 
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Quite honestly, I would call them and get clarification. Sometimes there just isn't a better denial reason so use, so they use a generic one instead.

It could be that the patient had a procedure elsewhere that you don't know about, or that you have to try procedures X, Y and Z before you can bill for these, or it could be a diagnosis issue...

I do know that Aetna's extremely strict about these situations, which is why I suggested looking for a medical policy. But again, rather than hunting and pecking around, a phone call might serve you best.
 
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