# 019-- Pain Mgmt-Aetna Denials??



## mchamberlain (Sep 3, 2015)

Wanted to see if anyone has any insight or experience with Aetna denying 019-- codes for pain management, denying for medical necessity.
 Our office does anesthesia & pain management billing.

We are able to submit for reconsideration & appeal, to get a very small amount of them reprocessed & paid, but most remain denied.

This seems to only be an issue with Aetna. There are some denials from Humana, but we've been able to appeal and get them paid.

Does anyone have any insight? Not sure what others are doing with these denials.

Thanks.


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## mitchellde (Sep 3, 2015)

What was the dx used?  Many times depending on the service or drug provided they want a 338.- dx code first listed


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## verrille01 (Sep 27, 2016)

Have had this happen to us too recently.  They have no published policy.  They have told me to go to NaviNet and look up McKesson policies, which are nowhere to be found and why other company policies apply is beyond me since they are not insurance companies.  Then they told me to fax them a request for the policy on all the anesthesia codes we want to know about.  Talk about illegal, having hidden policies.  It causes another problem because in NY there is a no surprise bill law that was passed in part because of large anesthesia bills patients would get.  So the doctors cannot bill the patient unless the patient agrees ahead of time and the insurance wont pay because they are frauds.  I will re-post if I have anything in writing, but if you have gotten any info please share too.  Thanks


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## KMCFADYEN (Oct 4, 2016)

Which CPT and ICD-10 codes are you billing and what is the specific denial?


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## dwaldman (Oct 11, 2016)

I am aware of McKesson policies that you have to purchase a license to view but Aetna has a policy for pain management as recent as April 2016 for common pain management procedures. The additional McKesson policy might have more medical necessity criteria described that they are basing their decisions but the general information seems to be able to be obtained as seen below if this pertaining to these types of procedures.

http://www.aetna.com/cpb/medical/data/1_99/0016.html

Number:*0016

Policy History
Last Review*04/26/2016 
Effective:*07/31/1995
Next Review:*01/07/2017
Policy 
Aetna considers any of the following injections or procedures medically necessary for the treatment of back pain; provided, however, that only*1 invasive modality or procedure will be considered medically necessary at a time.

Facet joint injections*(intra-articular and medial branch blocks)*are considered medically necessary in the diagnosis of facet pain*in persons with*chronic back or neck pain (pain lasting more than 3 montfhs despite appropriate conservative treatment).

Facet joint injections*(intra-articular and medial branch blocks)*are considered experimental and investigational as therapy for back and neck pain and*for all other indications because*their effectiveness for these indications has not been established.
A set of facet joint injections (intra-articular or medial branch blocks)*means up to 6 such injections per sitting, and this can be repeated*once at the same levels and side*to establish the diagnosis.**Additional sets of facet injections or medial branch blocks*at the same levels and side are considered experimental and investigational because they have no proven value.*

Aetna considers ultrasound guidance of facet injections experimental and investigational because of insufficient evidence of its effectiveness.*

Trigger point injections of corticosteroids and/or local anesthetics, are considered medically necessary for treating members with chronic neck or back pain or myofascial pain syndrome, when all of the following selection criteria are met:
Conservative therapies such as bed rest, exercises, heating or cooling modalities, massage, and pharmacotherapies such as non-steroidal anti-inflammatory drugs (NSAIDS), muscle relaxants, non-narcotic analgesics, should have been tried and failed, and
Symptoms have persisted for more than 3 months, and

Trigger points have been identified by palpation; and
Trigger point injections are not administered in isolation, but are provided as part of a comprehensive pain management program, including physical therapy, patient education, psychosocial support, and oral medication where appropriate.
Trigger point injections are considered experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above*has not been established.
A trigger point is defined as a specific point or area where, if stimulated by touch or pressure, a painful response will be induced.* A set of trigger point injections means injections in several trigger points in one sitting.* It is not considered medically necessary to repeat injections more frequently than every 7 days.* Up to 4*sets of injections are considered medically necessary to diagnose the origin of a patient's pain and achieve a therapeutic effect; additional sets of trigger point injections are not considered medically necessary if no clinical response is achieved.* Once a diagnosis is established and a therapeutic effect is achieved, it is rarely considered medically necessary to repeat trigger point injections more frequently than once every*2 months.* Repeated injections extending beyond 12 months may be reviewed for continued medical necessity.

Sacroiliac joint injections are considered medically necessary to relieve pain associated with lower lumbosacral disturbances in members who meet both of the following criteria:
Member has back pain for more than 3 months; and
The injections are not used in isolation, but are provided as part of a comprehensive pain management program, including physical therapy, patient education, psychosocial support, and oral medication where appropriate.

Sacroiliac joint injections are considered experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above has not been established.
Up to*2 sacroiliac injections are considered medically necessary to diagnose the patient's pain and achieve a therapeutic effect. *It is not considered medically necessary to repeat these injections more frequently than once every 7 days.* If the member experiences no symptom relief or functional improvement after*2 sacroiliac joint injections, additional sacroiliac joint injections are not considered medically necessary.* Once the diagnosis is established, it is rarely medically necessary to repeat sacroiliac injections more frequently than once every*2 months.* Repeat injections extending beyond 12 months may be reviewed for continued medical necessity.* Ultrasound guidance of sacroiliac joint injections is considered not medically necessary.

Epidural injections of corticosteroid preparations (e.g., Depo-Medrol), with or without added anesthetic agents, are considered medically necessary in the outpatient setting for management of persons with radiculopathy or sciatica when all of the following are met:
Intraspinal tumor or other space-occupying lesion, or non-spinal origin for pain, has been ruled out as the cause of pain; and
Member has failed to improve after*2 or more weeks of conservative measures (e.g., rest, systemic analgesics and/or physical therapy); and
Epidural injections beyond the first set of*3 injections are provided as part of a comprehensive pain management program, which includes physical therapy, patient education, psychosocial support, and oral medications, where appropriate.

Epidural injections of corticosteroid preparations, with or without added anesthetic agents, are considered experimental and investigational for all other indications (e.g., non-specific low back pain [LBP] and failed back syndrome) because their effectiveness for indications other than the ones listed above has not been established.
Repeat epidural injections beyond the first set of*3 injections are considered medically necessary when provided as part of a comprehensive pain management program, which includes physical therapy, patient education, psychosocial support, and oral medications, where appropriate.* Repeat epidural injections more frequently than every 7 days are not considered medically necessary.* Up to*3 epidural injections are considered medically necessary to diagnose a member's pain and achieve a therapeutic effect; if the member experiences no pain relief after three epidural injections, additional epidural injections are not considered medically necessary.* Once a therapeutic effect is achieved, it is rarely medically necessary to repeat epidural injections more frequently than once every*2 months. *In selected cases where more definitive therapies (e.g., surgery) can not be tolerated or provided, additional epidural injections may be considered medically necessary.* Repeat injections extending beyond 12 months may be reviewed for continued medical necessity.*

Aetna considers ultrasound guidance of epidural injections experimental and investigational because of insufficient evidence of its effectiveness.


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## KMCFADYEN (Oct 11, 2016)

In addition, Aetna has some frequency limitations for Facet injection.  
They will only allow 2 sets per region in any three year period.


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