05/10/2018

DME Denials for L3000 (Non-Diabetic Patients)-Aetna Commercial Health Plan

Aetna Commercial Plan DME denials for L3000 for non-diabetic patients. Upon contacting Aetna for authorization for L3000 we are told that it is covered by the patient's plan with the diagnosis of plantar fasciitis, and given a reference number to that effect. Thereafter we receive a denial indicating the orthotics are "excluded from the member's plan". Upon calling the claims department, they again confirm patient has coverage and send the claim back for reprocessing. Subsequently, we receive a denial upholding the original decision. Upon contacting Aetna we are told that the claim is denying based on medical necessity and that the code M72.2 is invalid. The policy online clearly states that if the patient's plan does not exclude coverage, M72.2 is a covered code. Any advice how to get these claims paid?

It is recommended that you file an appeal with Aetna and include the following information:

• Include the section of the patients benefits that states that orthotics are not excluded from coverage and are covered with the diagnosis of plantar faciitis 
• Have a transcript/summary of when customer service was contacted with reference numbers to confirm coverage and dispute the denial
• Copy the Aetna policy on orthotics 
• Submit all pertinent medical records to justify medical necessity 

It may be necessary to include the patient on any of the correspondence. It is important to involve the patient and include them in the process since the patient is the subscriber and can aid in the process. Insurance companies when notified by their members of any issues will be forced to address the request for payment. 

With all of the above documentation sent to the correct department, the denial should be reversed.