General Surgery Coding Alert

Question: We recently got a denial from Aetna for an EGD procedure for a 10-year-old patient with abdominal pain. The EOB stated that the procedure was not medically necessary. Do we have a basis for appeal?

Codify Subscriber

Answer: You may not have the basis for an appeal unless the surgeon’s documentation provides specific information that supports medical necessity.

Start here: Look at your payer’s coverage policy for esophagogastroduodenoscopy (EGD) to see what conditions Aetna excludes from EGD payment. To read Aetna’s policy, visit www.aetna.com/cpb/medical/data/700_799/0738.html.

You can see that “Aetna considers EGD (screening, diagnostic, therapeutic, or sequential/periodic) experimental and investigational for … Routine evaluation of abdominal pain in children (i.e., without other signs and symptoms suggestive of serious organic disease).”

If the pediatric patient does, in fact, have other signs and symptoms suggestive of serious organic disease and the surgeon has documented those in the medical record, you may have the basis to appeal the claim. You should submit copies of the documentation with the appeal letter, which show that the patient’s other signs and symptoms that warranted the EGD. The surgeon’s letter should explain why EGD was the best choice for diagnosing the patient in light of the patient’s signs and symptoms.