Wiki J1100 - Experimental

[CarlaA]

I work for a small general practice facility. We have 7 providers and they all use Decadron, J1100, for illnesses that cause inflammation, ie: sinusitis, allergic rhinitis, myalgia, etc. We are currently getting consistent denials from Aetna for this medication as experimental. All other insurances are paying for this service. Is anyone else having this issue or can help guide us in the right direction? Calling the insurance has given us little guidance or information.

The exact denial reads, "55 - Procedure/treatment/drug is deemed experimental/investigational by the payer; N623 - Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate"

 

[shanamarie]

I work for a small general practice facility. We have 7 providers and they all use Decadron, J1100, for illnesses that cause inflammation, ie: sinusitis, allergic rhinitis, myalgia, etc. We are currently getting consistent denials from Aetna for this medication as experimental. All other insurances are paying for this service. Is anyone else having this issue or can help guide us in the right direction? Calling the insurance has given us little guidance or information.

The exact denial reads, "55 - Procedure/treatment/drug is deemed experimental/investigational by the payer; N623 - Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate"

What injection code is being billed with it? My thought is it’s a diagnosis issue. Did you review the LCD?

 

[CarlaA]

We are billing it with administration code 96372. They seem to be denying all injectable steroids(J1100 & J0702.) We thought diagnosis issue at first as well but it is only Aetna denying with the diagnosis code J01.90(sinusitis) & J30.9(allergic rhinitis). I just can't make sense of the "experimental" denial since all other insurances including Medicare are paying with these CPT and Dx codes.

 

[IndepCoder]

I work for a small general practice facility. We have 7 providers and they all use Decadron, J1100, for illnesses that cause inflammation, ie: sinusitis, allergic rhinitis, myalgia, etc. We are currently getting consistent denials from Aetna for this medication as experimental. All other insurances are paying for this service. Is anyone else having this issue or can help guide us in the right direction? Calling the insurance has given us little guidance or information.

The exact denial reads, "55 - Procedure/treatment/drug is deemed experimental/investigational by the payer; N623 - Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate"

I work for a small general practice facility. We have 7 providers and they all use Decadron, J1100, for illnesses that cause inflammation, ie: sinusitis, allergic rhinitis, myalgia, etc. We are currently getting consistent denials from Aetna for this medication as experimental. All other insurances are paying for this service. Is anyone else having this issue or can help guide us in the right direction? Calling the insurance has given us little guidance or information.

The exact denial reads, "55 - Procedure/treatment/drug is deemed experimental/investigational by the payer; N623 - Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate"

 

[IndepCoder]

Are you using a NDC number to validate the J1100 is good? Try checking the Aetna drug list or contract on drugs and supply coverage.

 

[CarlaA]

We are using NDC number. We will definitely look into Aetna further....thank you

 

[CodingKing]

You will want to review the various Aetna policies.

For example they find Intramuscular (IM) steroids for the treatment of acute sinusitis and allergic rhinitis experimental and investigational

http://www.aetna.com/cpb/medical/data/1_99/0038.html

Aetna considers the following treatments experimental and investigational as they have not been proven to be effective:

• Acupuncture for allergies
• Allergoids (modification of allergens to reduce allergenicity)
• Autogenous urine immunization (autogenous urine therapy)
• Bacterial immunotherapy
• Chemical cautery of nasal mucosa for the treatment of allergic rhinitis
• Detoxification for allergies
• Ecology units/environmental control units/environmental chemical avoidance for multiple chemical sensitivity syndrome
• Enzyme potentiated desensitization (EPD)
• Helminth Trichuris suis therapy for allergic rhinitis
• Homeopathy for allergies
• Intradermal grass pollen immunotherapy for the treatment of allergic rhinitis
• Intramuscular (IM) steroids for the treatment of acute sinusitis and allergic rhinitis
• Neutralization therapy (desensitization neutralization therapy)
• Neutralizing therapy of chemical and food extracts
• Oral immunotherapy (OIT) for the treatment of food allergy
• Oral leukotriene receptor antagonists for allergic rhinitis
• Oral nystatin for the treatment of "candidiasis hypersensitivity syndrome"
• Photo-inactivated extracts
• Polymerized extracts
• Poison ivy/poison oak extracts for immunotherapy in the prevention of toxicodendron (Rhus) dermatitis
• Probiotics for food allergy prevention or treatment
• Repository emulsion therapy
• Rhinophototherapy
• Sublingual drops/sublingual immunotherapy other than Oralair, Grastek and Ragwitek. (Oralair and Grastek tablets are considered medically necessary for grass pollen allergies and Ragwitek is considered medically necessary for ragweed pollen allergies.) Footnotes*
• Sublingual immunotherapy for asthmatic children sensitized to house dust mite
• Treatments for electromagnetic sensitivity syndrome/disorder
• Ultra low dose enzyme activated immunotherapy (low dose allergens or LDA).
  Footnotes* Note: Some pharmacy benefit plans exclude allergy sera. This exclusion would apply to sublingual immunotherapy. Under plans with this exclusion, coverage of Oralair, Grastek, and Ragwitek may be available under the medical benefit. Please check benefit plan descriptions.