Gastroenterology Coding Alert

Question: We have been treating a patient with Remicade for years to treat her Crohn’s disease. Several months ago, we performed a colectomy and the patient is doing better. The patient returned last week for a Remicade infusion to prevent Crohn’s recurrence, but Aetna denied the Remicade charge this time, even though Aetna was the insurer paying for it before the surgery without a problem. What should we do?

Codify Subscriber

Answer: The solution lies in the reason you administered the Remicade infusion. Although Aetna does cover Remicade for active Crohn’s disease, the policy isn’t so accommo­dating after surgery.

Aetna’s policy specifically lists “Prevention of post-operative recurrence of Crohn’s disease” under its list of non-covered indications “because its effectiveness for these indications has not been established.” Therefore, unless there is an underlying issue in addition to what is stated in the question, it’s unlikely that Aetna will cover this patient’s infusion.

However, on a case-by-case basis, it may be possible to get coverage after a peer-to-peer discussion using available literature to support the use of Remicade for disease recurrence.