tci General Surgery Coding Alert - 2018 Issue 8

Reader Question: Use Payer Policy for Coverage Clues

Question: We recently got a denial from Aetna for an EGD procedure for a 10-year-old patient with abdominal pain. The EOB stated that the procedure was not medically necessary. Do we have a basis for appeal? SuperCoder Subscriber Answer: You may not have the basis for an appeal unless the surgeon’s documentation provides specific information that supports medical necessity. Start here: Look at your payer’s coverage policy for esophagogastroduodenoscopy (EGD) to see what conditions Aetna excludes from EGD payment. To read Aetna’s policy, visit www.aetna.com/cpb/medical/data/700_799/0738.html. You can see that “Aetna considers EGD...

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