Aetna Claims and Appeals Resources
Tuesday, May 06, 2014 07:36 AM

ACA has been regularly updating members on its progress with Aetna regarding the processing of claims containing 97140-59 and CMT. Our most recent release stated that Aetna agreed to pay for 97140 when billed with CMT, if provided to a separate region, and documentation for medical necessity was submitted with the claim.

Unfortunately, ACA has been made aware of wrongful denials of these claims in spite of the new Aetna policy. To assist our members with filing inital claims and appeals in these instances, ACA's Insurance Relations Department has created the following resources:

ACA has been made aware that there remains confusion surrounding what constitutes a region. We would like to remind our members that it is appropriate to bill according to CPT® criteria, as billing according to any other standard will not result in payment from Aetna.

The five regions, according to CPT, are: Cervical (includes atlanto-occipital joint), Thoracic (includes costovertebral and costotransverse joints), Lumbar, Sacral, and Pelvic (sacro-iliac joint) (these spinal groups are not to be confused with different tissue groups within the same area).

The five extraspinal regions are: head region (including temporomandibular joint, excluding atlantooccipital); lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints); and abdomen.