# Tysabri Infusion for Multiple Sclerosis denied



## hcg

I'm new to this billing practice & I need help on a claim that was denied by Aetna.

Patient is being seen in the Doctor's office for Natalizumab (Tysabri) infusion. Pt has Multiple Sclerosis, Optic neuritis, & numbness, parasthesia. Here are the codes on the claim:

Dx codes - 340, 377.30, 782.0

CPT codes - 96413, 96415, A4221, A4222

Aetna denied as: The charge for this service does not meet this requirement of the member's plan of benefits because the chemo administration codes were not billed with nonradionuclide antni-neoplastic drugs, anti-neoplastic agents used for treatment of non-cancer diagnoses, monoclonal anti-body agents & other  immunomodulator drugs.

The Dr. said that this is medically necessary. He wanted me to appeal & make sure it gets paid. Our biller told me to use 96365 & 96366. Is it appropriate to use CPT 96365 & 96366 instead? I'm confused. 

Your help is greatly appreciated.


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## ollielooya

Just wondering since you didn’t list the actual drug (Natalizumab) amongst your codes, it may be that Aetna does have foundation for their denial.  Why is not the actual drug listed??  Does patient get it from the pharmacy?  And yes, I am inclined to agree with your biller.  Without the drug, you would bill the 96365 and 96366.

We’re having the same issue with Aetna for the Remicade medications provided by the pharmacy for the infusion treatment.  Claim gets denied for your same reason because the actual  "qualifying" drug was not submitted on the claim form.  So what we are doing now to resolve the issue is to still bill for the Remicade with the accurate number of units and assign a $0.0 charge.   We're waiting to see if that will work.


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## hcg

Hi Susan,

Yes you were right, patients get their drug from the pharmacy. So Dr. does not include the J code. Thanks for the information.

So, if you put the drug with a $0.00 charge, can we still bill with the same code 96413 & 96415?


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## ollielooya

It is my understanding that if the drug that is administered FITS the criteria of using those more advanced infusion codes that yes, you still bill the 96413 and 96415. Otherwise, it appears you may have to use the other codes your biller mentioned.  Make sure you fill it in with the proper units just like you would if you were going to bill out the medication and try adding the $0.00 charge and see if that works.  We're hoping it works for us.


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## hcg

I greatly appreciate your help. I would definitely do that.


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## Gwen Davis

*J2323*

I agree, you should place the J2323 with the correct qty and (NDC if needed) and list only a zero charge amount.  Link it to the appropriate administration.  I think for this drug it would be Non chemo-   I know Aetna is not Medicare but here is the Noridian link for what drugs are considered chemotherapy.  

https://www.noridianmedicare.com/sh..._Administration_-_Revised_October_20_2011.htm


Here is Aetna's policy on J2323   There is a note about MS-Coverage-
http://www.aetna.com/cpb/medical/data/700_799/0751.html

Aetna considers natalizumab (Tysabri) medically necessary for the treatment of individuals with relapsing, remitting multiple sclerosis (but not for the treatment of chronic progressive multiple sclerosis) for persons with a contraindication, allergy, intolerance, or failure of a one-month trial of Avonex, Copaxone or Rebif.  See CPB 0264 - Multiple Sclerosis.

Hope this helps-


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## hcg

Hi Gwen,

Every information  helps. Whether it is Aetna or Medicare or other insurance, I need all information about this drug since I am new to this billing. It would help a lot.


Thank you so much.


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## SLITTLES

We bill Tysabri using the 96365 and 96366, we never bill for the medication because the patient gets it through the specialty pharmacy and I have never had a denial with Aetna.


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## ollielooya

It appears that for Aetna it all boils down to the actual classification of the drug administered.  If it does not fit into a certain "family" of pharmaceuticals that would warrant the 96413 and 96415, then yes, billing it with 96365 and 96366 would be the correct choice.  I'm not sure where that particular drug fits in, and most likely an Aetna policy search will provide that information.  And yes, 96365 and 96366 might be considered, but reimbursement would be half of that received with the other admin codes.  We're dealing with Aetna for the very same reason, but in our case, it's with REMICADE infusions when the patient obtains the medication thru the specialty pharmacy.


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## hcg

SLITTLES said:


> We bill Tysabri using the 96365 and 96366, we never bill for the medication because the patient gets it through the specialty pharmacy and I have never had a denial with Aetna.





SLITTLES - Thank you for the information, at least I know Aetna pays for 96365 & 96366 on Tysabri.


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## hcg

ollielooya said:


> It appears that for Aetna it all boils down to the actual classification of the drug administered.  If it does not fit into a certain "family" of pharmaceuticals that would warrant the 96413 and 96415, then yes, billing it with 96365 and 96366 would be the correct choice.  I'm not sure where that particular drug fits in, and most likely an Aetna policy search will provide that information.  And yes, 96365 and 96366 might be considered, but reimbursement would be half of that received with the other admin codes.  We're dealing with Aetna for the very same reason, but in our case, it's with REMICADE infusions when the patient obtains the medication thru the specialty pharmacy.





Suzanne - What I was confused of is that, the first 3 Date of Service, Aetna paid the codes 96413 & 96415. But the 4th & the 5th DOS, they denied it. I'm sure they will do take backs on the first 3 DOS.


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## ollielooya

It may be a question of the units of service over a specific time period.  They may be limited as to how many injections they will cover for. You might want to check the policy of that particular payer.  They might not request a take-back but if services are limited, your office may have to have other options in place.


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## hcg

You have given me a great suggestion. Thank you so much. I would definitely call Aetna regarding payer's policy.


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## mmathewscpc

hcg said:


> SLITTLES - Thank you for the information, at least I know Aetna pays for 96365 & 96366 on Tysabri.


thank you, i agree, it's not chemo, it's a biologic. i am now billing these two codes and not looking back!


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