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What codes for ABA therapy use for AETNA in NY

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ekochin:
We use 97532, but they said it is not ABA and denied it
thank you

Michele:
What is the exact denial you are receiving?  What diagnosis code are you using?

ekochin:
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.”]

Michele:
It sounds to me like it is a contract exclusion.  I'm not sure that there is anything you can do.

pankaj:
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

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