Wiki Aetna denying Facets

[abs1821]

One of the girls in the office spoke to Aetna this morning and they are now denying Facets/MBB's stating that a patient can not receive them more than twice in a 1095 day period...

Anyone else seeing these? Do we need to append a modifier that maybe we are unaware of or is this just something that just isn't going to allow us to get reimbursement?

 

[Melissa Harris CPC]

Here is the policy from Aetna on Facet Blocks

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

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.
I.
Facet joint injections (intraarticular 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 months despite appropriate conservative treatment).

Facet joint injections (intraarticular and medial branch blfocks) 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 (intraarticular or medial branch blocks) means up to 6 such injections per sitting, and this can be repeated once to establish the diagnosis. Additional sets of facet injections or medial branch blocks 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.



Melissa Harris, CPC
Albany and Saratoga Centers for Pain Management

 

[KMCFADYEN]

Aetna has an exremely strict medical policy on facet injections (64490-64495). The long and the short of it is that a patient can only receive 2 sets per region in a 3 year period. The region being cervical/thoracic or lumbar/sacral. If the physician feels the need for a third set, we have the patient sign an ABN that they will be responsible for charges and explain that Aetna will not pay as it is considered experimental and investigational. Appealing is futile as this is made clear in their back pain-invasive procedure clinical policy bulletin.