Ophthalmology and Optometry Coding Alert

Question: I’m suddenly getting denials from Aetna for Avastin. Are you aware of why this might be?

Codify Subscriber

Answer: It appears that Aetna quietly updated its Avastin billing policy in November, and began denying claims for some ophthalmic uses of the product shortly thereafter.

According to the policy, Avastin is payable for treating diabetic macular edema, macular edema after retinal vein occlusion, wet AMD, neovascular glaucoma, pseudoxanthoma elasticum, some uncommon causes of choroidal neovascularization, and retinopathy of prematurity.

However, the updated policy says that Aetna considers Avastin “experimental and investigational” for treating the following conditions, among others, “because their effectiveness for these indications has not been established:”

• Amblyopia
• Central serious retinopathy
• Cystoid macular edema
• Diabetic retinopathy without macular edema (including pre-treatment of vitrectomy for proliferative diabetic retinopathy)
• Glaucoma surgery for control of wound healing
• Primary pterygium
• Retinal angioma
• Vitreous hemorrhage not related to a medically necessary indication

You should work with your payer representatives at Aetna if this updated policy vastly impacts your income, and have your physician write a letter to the insurer’s medical director to explain the usefulness of Avastin for these conditions. 

To read more about Aetna’s updated policy, visit http://www.aetna.com/cpb/medical/data/700_799/0701.html.