Medical Billing Forum

Coding => Coding => Topic started by: ekochin on October 28, 2015, 11:41:47 AM

Title: What codes for ABA therapy use for AETNA in NY
Post by: ekochin on October 28, 2015, 11:41:47 AM
We use 97532, but they said it is not ABA and denied it
thank you
Title: Re: What codes for ABA therapy use for AETNA in NY
Post by: Michele on October 29, 2015, 12:19:22 PM
What is the exact denial you are receiving?  What diagnosis code are you using?
Title: Re: What codes for ABA therapy use for AETNA in NY
Post by: ekochin on October 30, 2015, 08:50:55 AM
The diagnosis is Autism: 299.0. We used 97532 CPT code ,they say it is not ABA it is cognitive Rehabilitation , then the letter of denial said - [“We reviewed information about your condition and circumstances. We used Aetna's Clinical Policy Bulletin (CPB): Cognitive Rehabilitation. Based on CPB criteria and the information we have, coverage for cognitive rehabilitation is denied. Medical studies have not proven that this procedure/service is safe and effective for treatment of your condition.
(Medical Necessity Denial) This coverage denial was based on the terms of the member's benefit
plan document (such as the Certificate of Coverage or benefit plan booklet/handbook, including any amendments or riders). The plan does not cover services that are not medically necessary. Please see the reference to non-medically necessary services listed in the Exclusions section of the benefit
plan document or refer to the description of medically necessary services in the Definitions or
Glossary section of the benefit plan document.”]
Title: Re: What codes for ABA therapy use for AETNA in NY
Post by: Michele on October 30, 2015, 10:38:24 AM
It sounds to me like it is a contract exclusion.  I'm not sure that there is anything you can do.
Title: Re: What codes for ABA therapy use for AETNA in NY
Post by: pankaj on October 30, 2015, 01:09:37 PM
you must talk to rendering provider if he/she can provide you enough medical records with their his/her notes that shows the rendered services was medically necessary. if have it then file an appeal if no then i dont think there is something to do with it .... good luck
Title: Re: What codes for ABA therapy use for AETNA in NY
Post by: PMRNC on October 31, 2015, 09:32:28 AM
If this is an ERISA plan, as the patient to bring in their SBP (Summary of Benefit Plan) and see if there are any exclusions for either the diagnosis or the treatment.

This is similar to a plan exclusion we run across for ADD/ADHD, many plans specifically exclude all coverage for both diagnosis. IF the actual SPB has this exclusion then most likely you will be billing the patient. IF NOT... then you can appeal.  Your appeal would be an ERISA appeal which means you can reference the employer,and the DOL and follow proper appeal procedures for ERISA. 

The APB reads like this: 

Note: Coverage of outpatient cognitive rehabilitation is subject to applicable benefit plan terms and limitations for physical and occupational therapy (see CPB 0250 - Occupational Therapy Services and CPB 0325 - Physical Therapy Services).  Please check benefit plan descriptions for details.

Aetna considers cognitive rehabilitation as adjunctive treatment of cognitive deficits (e.g., attention, language, memory, reasoning, executive functions, problem solving, and visual processing) medically necessary when all of the following are met:

Neuropsychological testing has been performed and neuropsychological results will be used in treatment-planning and directing rehabilitation strategies, and
The cognitive deficits have been acquired as a result of neurologic impairment due to traumatic brain injury, brain surgery, stroke, or encephalopathy, and
The member has been seen and evaluated by a neuropsychiatrist or neuropsychologist, and
The member is expected to make significant cognitive improvement (e.g., member is not in a vegetative or custodial state).
Note: Cognitive rehabilitation may be performed by an occupational therapist, physical therapist, speech/language pathologist, neuropsychologist, or a physician.

Note: According a review article on cognitive rehabilitation (Ciceron et al, 2000), rehabilitation for visuo-spatial deficits generally entails 20 1-hour sessions delivered over the course of 4 weeks.  For language and communication deficits, patients usually receive 8 hours of weekly therapy, beginning at 4 weeks post-onset and continuing up to 48 weeks post-onset.  Courses of cognitive rehabilitation substantially longer than these durations may be reviewed for medical necessity.

Aetna considers cognitive rehabilitation experimental and investigational for all other indications, such as the treatment of epilepsy/seizure disorders, mental retardation, cerebral palsy, dementia (e.g., from Alzheimer’s disease, HIV-infection*, or Parkinson’s disease), cognitive decline in multiple sclerosis and chronic obstructive pulmonary disease, Wernicke encephalopathy, and behavioral/psychiatric disorders such as attention-deficit/hyperactivity disorder, depression, schizophrenia, social phobia, substance abuse disorders, and pervasive developmental disorders including autism, as it has not been proven to be effective for these indications.
*Note: Cognitive rehabilitation is considered medically necessary for encephalopathy due to HIV when medical necessity criteria in section I above are met.

Aetna considers coma stimulation, also known as the "Responsiveness Program" (cognitive remediation of comatose persons), coma arousal program/therapy, sensory stimulation, and multi-sensory stimulation programs, experimental and investigational for coma and persistent vegetative state because its effectiveness has not been established..