Aetna Health Management HMO Products SouthEast Region (Including Arkansas) Medical and Non-Medical Approvals and Denials from 01/01/2017 to 03/31/2017
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1 Aetn Helth Mngement HMO Products SouthEst Region (Including Arknss) Medicl nd Non-Medicl Approvls nd Denils from 01/01/2017 to 03/31/2017 Code Inptient Medicl nd Non-Medicl Approvls nd Denils Top 10 Provider/Fcility Types Internl Medicine 808 Surgery, Orthopedic 334 Psychitry 211 Surgery 206 Fmily Prctice 195 Obstetrics & Gynecology 166 Surgery, Neurologicl 153 Acute Short Term Hospitl 142 Generl Prctice 120 Peditrics 65 Top 10 Codes nd Descriptions Code Description TOTAL KNEE ARTHROPLASTY TOTAL HIP ARTHROPLASTY TOTAL HYSTERECTOMY MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS, BY CABLE OR RADIO 16 OR MORE CHANEL TELEMETRY COMBINED ELECTROENCEPHALOGRAPHIC (EEG) AND VIDEO RECORDING AND INTERPRETATION,(EG, PRESURGICAL LOCALIZATION) EACH 24 HOURS 9 Ambultory Medicl nd Non-Medicl Approvls nd Denils Top 10 Provider/Fcility Types Applied Behviorl Anlysis 74 Psychitry 66 Surgery, Orthopedic 57 Clinicl Psychologist 54 Fmily Prctice 48 Internl Medicine 41 Neurology 32 Endocrinology, Reproductive 30 Surgery, Neurologicl 29 Clinicl Socil Worker 26 Top 10 Codes nd Descriptions Code Code Description G0379 DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE 64 H2036 ALCOHOL AND/OR DRUG TREATMENT PROGRAM, PER DIEM 42 H0015 ALCOHOL AND/OR DRUG SERVICES; INTENSIVE OUTPATIENT PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI, RORSCHACH, WAIS), PER HOUR OF THE PSYCHOLOGIST'S OR PHYSICIAN'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TEST 28 Pge 1 of 6
2 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING 8 LAPAROSCOPY, SURGICAL;COLECTOMY, PARTIAL, WITH ANASTOMOSIS 8 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; INITIATION OF PROLONGED CHEMOTHERAPY INFUSION (MORE THAN 8 HOURS) 7 ARTHRODESIS, ANTERIOR INTERBODY; CERVICAL BELOW C2 (FUSION) 7 LAPAROSCOPY, SURGICAL PROSTATECTOMY DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE 3 Top 10 Dignosis Codes nd Descriptions Dignosis code Dignosis Code Description R07.9 CHEST PAIN, UNSPECIFIED 65 R10.9 UNSPECIFIED ABDOMINAL PAIN 53 F10.20 ALCOHOL DEPENDENCE, UNCOMPLICATED 52 M17.11 UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT KNEE 45 J18.9 PNEUMONIA, UNSPECIFIED ORGANISM 45 F32.9 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED T ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN, FACE-TO-FACE WITH ONE PATIENT; FIRST 30 MINUTES OF TECHNICIAN TIME 23 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT H Dignosis code ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, PERCUTANEOUS,LASER, FIRST VEIN TREATED 21 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS 17 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED 17 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION 14 Top 10 Dignosis Codes nd Descriptions Dignosis Code Description F84.0 AUTISTIC DISORDER 80 F10.20 ALCOHOL DEPENDENCE, UNCOMPLICATED 45 I87.2 VENOUS INSUFFICIENCY (CHRONIC) (PERIPHERAL) 27 N97.9 FEMALE INFERTILITY, UNSPECIFIED 26 G60.0 HEREDITARY MOTOR AND SENSORY NEUROPATHY 22 F11.20 OPIOID DEPENDENCE, UNCOMPLICATED 21 Pge 2 of 6
3 F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 42 M48.06 SPINAL STENOSIS, LUMBAR REGION 39 A41.9 SEPSIS, UNSPECIFIED ORGANISM 37 M16.12 UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT HIP 36 Top 10 Denil Resons MCG: Post -Adm 35 MCG: Abdominl Pin-Adm 32 MCG: Chest Pin-Adm 24 Lumbr spinl fusion - (VIII) 15 Investigtionl/Experimentl 13 MCG: Systemic or Infectious Condition-Adm 12 Not Mediclly Necessry 9 IP Admit Denil Due to Denil by evicore 7 MCG: Renl Colic nd Kidney Stones - Adm 7 MCG: Alcohol/Drug Overdose-Adm 5 IP Admit Denil Due to Denil (Clin) 5 M48.06 SPINAL STENOSIS, LUMBAR REGION 18 Z63.6 DEPENDENT RELATIVE NEEDING CARE AT HOME 14 M51.26 OTHER INTERVERTEBRAL DISC DISPLACEMENT, LUMBAR REGION 13 M50.30 OTHER CERVICAL DISC DEGENERATION, UNSPECIFIED CERVICAL REGION 13 Top 10 Denil Resons Network Adequcy Denil: No Out of Network Benefits 26 Pln exclusion 21 Not Covered Service 11 Must Customize BH ABA - Tretment Hours 10 Non Pr 10 No Clinicl Info Denil 8 Vricose Veins: No Duplex/Ultrsound 7 Level of Cre 7 Coverge Terminted Prior to Service Dtes 7 EMG monitoring - Intropertive spinl surgery 5 Not Mediclly Necessry 5 Pge 3 of 6
4 Aetn Life Insurnce Compny PPO Products SouthEst Region (Including Arknss) Medicl nd Non-Medicl Approvls nd Denils from 01/01/2017 to 03/31/2017 Inptient Medicl nd Non-Medicl Approvls nd Denils Top 10 Provider/Fcility Types Internl Medicine 764 Surgery, Orthopedic 443 Psychitry 337 Surgery 297 Surgery, Neurologicl 272 Obstetrics & Gynecology 162 Fmily Prctice 152 Generl Prctice 142 Peditrics 117 Acute Short Term Hospitl 98 Top 10 Codes nd Descriptions Code Code Description TOTAL KNEE ARTHROPLASTY TOTAL HIP ARTHROPLASTY TOTAL HYSTERECTOMY LAPAROSCOPY, SURGICAL PROSTATECTOMY TOTAL SHOULDER ARTHROPLASTY 8 Ambultory Medicl nd Non-Medicl Approvls nd Denils Top 10 Provider/Fcility Types Psychitry 172 Surgery, Orthopedic 87 Clinicl Psychologist 76 Applied Behviorl Anlysis 63 Endocrinology, Reproductive 57 Surgery, Neurologicl 57 Internl Medicine 55 Unknown 37 Obstetrics & Gynecology 37 Surgery, Plstic 34 Surgery 34 Top 10 Codes nd Descriptions Code Code Description H2036 ALCOHOL AND/OR DRUG TREATMENT PROGRAM, PER DIEM 70 H0015 ALCOHOL AND/OR DRUG SERVICES; INTENSIVE OUTPATIENT 61 G0379 DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE 61 H0035 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI, RORSCHACH, WAIS), PER HOUR OF THE PSYCHOLOGIST'S OR PHYSICIAN'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TEST LAPAROSCOPY, SURGICAL;COLECTOMY, PARTIAL, WITH ANASTOMOSIS ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED 25 Pge 4 of 6
5 MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS, BY CABLE OR RADIO 16 OR MORE CHANEL TELEMETRY COMBINED ELECTROENCEPHALOGRAPHIC (EEG) AND VIDEO RECORDING AND INTERPRETATION,(EG, PRESURGICAL LOCALIZATION) EACH 24 HOURS 6 ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE; LUMBAR (FUSION) 6 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE; LUMBAR (FUSION) MYOMECTOMY, EXCISION OF FIRBROID TUMORS OF UTERUS; ABDOMINAL APPROACH ARTHRODESIS, ANTERIOR INTERBODY; CERVICAL BELOW C2 (FUSION) 6 Top 10 Dignosis Codes nd Descriptions Dignosis code Dignosis Code Description F10.20 ALCOHOL DEPENDENCE, UNCOMPLICATED 102 M48.02 SPINAL STENOSIS, CERVICAL REGION 78 F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 69 R07.9 CHEST PAIN, UNSPECIFIED 62 F11.20 OPIOID DEPENDENCE, UNCOMPLICATED 61 J18.9 PNEUMONIA, UNSPECIFIED ORGANISM 54 M17.11 UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT KNEE 53 M16.11 UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT HIP 50 F32.9 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE 48 R10.9 UNSPECIFIED ABDOMINAL PAIN 47 M17.12 UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE 47 Top 10 Denil Resons CHEST PAIN, UNSPECIFIED 18 SPINAL STENOSIS, CERVICAL REGION 11 PNEUMONIA, UNSPECIFIED ORGANISM 8 S9480 INTENSIVE OUTPATIENT PSYCHIATRIC SERVICES, PER DIEM LAMINOTOMY (HEMILAMINECTOMY), LUMBAR 21 J0725 INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS T ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN, FACE-TO-FACE WITH ONE PATIENT; FIRST 30 MINUTES OF TECHNICIAN TIME 17 Dignosis code Top 10 Dignosis Codes nd Descriptions Dignosis Code Description F84.0 AUTISTIC DISORDER 102 F10.20 ALCOHOL DEPENDENCE, UNCOMPLICATED 85 N97.9 FEMALE INFERTILITY, UNSPECIFIED 54 F11.20 OPIOID DEPENDENCE, UNCOMPLICATED 53 F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 44 S88.111S COMPLETE TRAUMATIC AMPUTATION AT LEVEL BETWEEN KNEE AND ANKLE, RIGHT LOWER LEG, SEQUELA 25 M48.02 SPINAL STENOSIS, CERVICAL REGION 25 I VARICOSE VEINS OF BILATERAL LOWER EXTREMITIES WITH PAIN 21 F41.9 ANXIETY DISORDER, UNSPECIFIED 20 M51.26 OTHER INTERVERTEBRAL DISC DISPLACEMENT, LUMBAR REGION 17 Top 10 Denil Resons Pln exclusion 27 Not Mediclly Necessry 23 Not Covered Service 16 Pge 5 of 6
6 UNSPECIFIED ABDOMINAL PAIN 6 UNSPECIFIED ATRIAL FIBRILLATION 6 SPINAL STENOSIS, LUMBAR REGION 5 GASTROINTESTINAL HEMORRHAGE, UNSPECIFIED 5 ALCOHOL DEPENDENCE, UNCOMPLICATED 4 HEADACHE 4 ANEMIA, UNSPECIFIED 4 MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES 4 No Clinicl Info Denil 15 Level of Cre 10 Coverge Terminted Prior to Service Dtes 9 Cervicl lminectomy nd/or ACDF 7 Cervicl, lumbr, or thorcic lmiá (other thn hernited disk) 5 Non Prticipting 5 Not Covered Service 4 No Info PDN 4 Pge 6 of 6
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