Aetna Health Management HMO Products SouthEast Region (Including Arkansas) Medical and Non-Medical Approvals and Denials from 04/01/2017 to 06/30/2017
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1 Aetn Helth Mngement HMO Products SouthEst Region (Including Arknss) Medicl nd Non-Medicl Approvls nd Denils from 04/01/2017 to 06/30/2017 Code Inptient Medicl nd Non-Medicl Approvls nd Denils Top 10 Provider/Fcility Types Internl Medicine 872 Surgery, Orthopedic 289 Surgery, Neurologicl 206 Surgery 200 Fmily Prctice 171 Psychitry 149 Obstetrics & Gynecology 129 Generl Prctice 103 Acute Short Term Hospitl 86 Peditrics 75 Top 10 Codes nd Descriptions Code Description TOTAL KNEE ARTHROPLASTY TOTAL HIP ARTHROPLASTY 16 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE; LUMBAR (FUSION) TOTAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S) 10 LAPAROSCOPY, SURGICAL;COLECTOMY, PARTIAL, WITH ANASTOMOSIS 9 Ambultory Medicl nd Non-Medicl Approvls nd Denils Top 10 Provider/Fcility Types Surgery, Orthopedic 80 Internl Medicine 67 Applied Behviorl Anlysis 52 Psychitry 51 Clinicl Psychologist 33 Fmily Prctice 29 Surgery, Generl Vsculr 28 Obstetrics & Gynecology 26 Gstroenterology 25 Surgery 24 Top 10 Codes nd Descriptions Code Code Description G0379 DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE ALCOHOL AND/OR DRUG TREATMENT PROGRAM, PER DIEM 28 H0015 ALCOHOL AND/OR DRUG SERVICES; INTENSIVE OUTPATIENT H2036 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 22 ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN, FACE-TO-FACE WITH ONE PATIENT; FIRST 30 MINUTES OF TECHNICIAN TIME 20 Pge 1 of 6
2 Dignosis code 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 LAPAROSCOPY, SURGICAL PROSTATECTOMY 8 ARTHRODESIS, ANTERIOR INTERBODY; CERVICAL BELOW C2 (FUSION) 7 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; CAROTID MASTECTOMY, SIMPLE, COMPLETE 5 REPLACEMENT, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS 5 Top 10 Dignosis Codes nd Descriptions Dignosis Code Description R10.9 UNSPECIFIED ABDOMINAL PAIN 64 R07.9 CHEST PAIN, UNSPECIFIED 54 F10.20 ALCOHOL DEPENDENCE, UNCOMPLICATED 50 J18.9 PNEUMONIA, UNSPECIFIED ORGANISM 46 M17.12 UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE 44 M48.06 SPINAL STENOSIS, LUMBAR REGION 42 A41.9 SEPSIS, UNSPECIFIED ORGANISM INJECTION, ONABOTULINUMTOXINA, 1 UNIT T H0035 J0897 J0585 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, PERCUTANEOUS,LASER, FIRST VEIN TREATED 15 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS 15 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED 14 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 12 Top 10 Dignosis Codes nd Descriptions Dignosis code Dignosis Code Description F84.0 AUTISTIC DISORDER 70 I87.2 VENOUS INSUFFICIENCY (CHRONIC) (PERIPHERAL) 41 F10.20 ALCOHOL DEPENDENCE, UNCOMPLICATED 36 N97.9 FEMALE INFERTILITY, UNSPECIFIED 19 F11.20 OPIOID DEPENDENCE, UNCOMPLICATED 16 Z85.3 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST 15 M53.2X7 SPINAL INSTABILITIES, LUMBOSACRAL REGION 13 Pge 2 of 6
3 M17.11 UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT KNEE 38 L03.90 CELLULITIS, UNSPECIFIED 29 Top 10 Denil Resons No Clinicl Info Denil 172 Other Coverge Primry/COB 39 MCG: Post -Adm 28 Network Adequcy Denil: No Out of Network Benefits 19 MCG: Abdominl Pin-Adm 19 Lumbr spinl fusion - (VIII) 14 MCG: Chest Pin-Adm 13 Coverge Terminted Prior to Service Dtes 12 MCG: Systemic or Infectious Condition-Adm 12 DRG Continution of Recent Admission 11 F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 13 G82.53 QUADRIPLEGIA, C5-C7 COMPLETE 13 R07.9 CHEST PAIN, UNSPECIFIED 12 I VARICOSE VEINS OF BILATERAL LOWER EXTREMITIES WITH OTHER COMPLICATIONS 12 Top 10 Denil Resons Network Adequcy Denil: No Out of Network Benefits 23 MUST CUSTOMIZE - Not Mediclly Necessry 19 Pln exclusion 15 MUST CUSTOMIZE - Level of Cre 9 Vricose Veins: No Duplex/Ultrsound 5 MUST CUSTOMIZE - Investigtionl/Experimentl 5 No Clinicl Info Denil 5 Must Customize BH ABA - Tretment Hours 4 Lumbr spinl fusion - (VIII) 4 Vricose Veins 3 Custodil - Home Cre 3 Pge 3 of 6
4 Aetn Life Insurnce Compny PPO Products SouthEst Region (Including Arknss) Medicl nd Non-Medicl Approvls nd Denils from 04/01/2017 to 06/30/2017 Inptient Medicl nd Non-Medicl Approvls nd Denils Top 10 Provider/Fcility Types Internl Medicine 723 Surgery, Orthopedic 403 Surgery 283 Ambultory Medicl nd Non-Medicl Approvls nd Denils Top 10 Provider/Fcility Types Psychitry 130 Surgery, Orthopedic 100 Surgery, Neurologicl 95 Code Psychitry 271 Surgery, Neurologicl 189 Obstetrics & Gynecology 176 Fmily Prctice 149 Peditrics 115 Generl Prctice 98 Emergency Medicine 70 Top 10 Codes nd Descriptions Code Description TOTAL KNEE ARTHROPLASTY TOTAL HIP ARTHROPLASTY TOTAL HYSTERECTOMY 17 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; (SLEEVE GASTRECTOMY) ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE; LUMBAR (FUSION) LAPAROSCOPY, SURGICAL PROSTATECTOMY 6 Internl Medicine 82 Applied Behviorl Anlysis 71 Clinicl Psychologist 67 Clinicl Socil Worker 61 Surgery, Plstic 60 Surgery 45 Generl Prctice 42 Fmily Prctice 42 Top 10 Codes nd Descriptions Code Code Description H0035 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS 69 G0379 DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE 66 H2036 ALCOHOL AND/OR DRUG TREATMENT PROGRAM, PER DIEM 58 H0015 ALCOHOL AND/OR DRUG SERVICES; INTENSIVE OUTPATIENT ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS,LASER, FIRST VEIN TREATED 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 40 Pge 4 of 6
5 63047 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY SINGLE VERTEBRAL SEGMENT; LUMBAR ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED 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 GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH INTERPRETATION AND REPORT MYOMECTOMY, EXCISION OF FIRBROID TUMORS OF UTERUS; ABDOMINAL APPROACH BREAST RECONSTRUCTION ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE ; LUMBAR (FUSION) LAPAROSCOPY, SURGICAL; COLECTOMY (LOW PELVIC ANASTOMOSIS) LAPAROSCOPY, SURGICAL;COLECTOMY, PARTIAL, WITH REMOVAL OF TERMINAL ILEUM WITH ILEOCOLOSTOMY 5 Top 10 Dignosis Codes nd Descriptions Dignosis code Dignosis Code Description F10.20 ALCOHOL DEPENDENCE, UNCOMPLICATED 118 F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 68 R07.9 CHEST PAIN, UNSPECIFIED 51 R10.9 UNSPECIFIED ABDOMINAL PAIN 49 F11.20 OPIOID DEPENDENCE, UNCOMPLICATED 48 M17.11 UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT KNEE 48 A41.9 SEPSIS, UNSPECIFIED ORGANISM 43 M48.06 SPINAL STENOSIS, LUMBAR REGION 43 J18.9 PNEUMONIA, UNSPECIFIED ORGANISM T BEHAVIOR IDENTIFICATION ASSESSMENT, BY THE PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FACE-TO-FACE WITH PATIENT AND CAREGIVER(S),INCLUDES ADMINISTRATION OF STANDARDIZED AND NON-STANDARDIZED TESTS, DETAILED BEHAVIORAL HISTORY, PATIENT OBSERVAT LAMINOTOMY (HEMILAMINECTOMY), LUMBAR 25 Top 10 Dignosis Codes nd Descriptions Dignosis code Dignosis Code Description F84.0 AUTISTIC DISORDER 107 F10.20 ALCOHOL DEPENDENCE, UNCOMPLICATED 77 F11.20 OPIOID DEPENDENCE, UNCOMPLICATED 55 N97.9 FEMALE INFERTILITY, UNSPECIFIED 49 F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 33 I VARICOSE VEINS OF BILATERAL LOWER EXTREMITIES WITH PAIN 32 M48.02 SPINAL STENOSIS, CERVICAL REGION 30 I87.2 VENOUS INSUFFICIENCY (CHRONIC) (PERIPHERAL) 28 M51.26 OTHER INTERVERTEBRAL DISC DISPLACEMENT, LUMBAR REGION 23 Pge 5 of 6
6 M17.12 UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE 34 Top 10 Denil Resons No Clinicl Info Denil 260 MCG: Post -Adm 28 MCG: Abdominl Pin-Adm 21 MCG: Chest Pin-Adm 19 DRG Continution of Recent Admission 19 Coverge Terminted Prior to Service Dtes 17 Other Coverge Primry/COB 15 Level of Cre 13 Not Mediclly Necessry 13 ASAM CD RTC - withdrwl mngement services 9 MCG: Gstroenteritis 9 Z47.2 ENCOUNTER FOR REMOVAL OF INTERNAL FIXATION DEVICE 20 Top 10 Denil Resons Not Mediclly Necessry 66 Pln exclusion 52 No Clinicl Info Denil 48 Level of Cre 18 Custodil - Home Cre 14 Must Customize BH ABA - Tretment Hours 10 Spine cges for cervicl fusion 10 Brest Reduction: Brest Tissue Surfce Are 10 Investigtionl/Experimentl 10 Cosmetic Surgery 8 Pnniculectomy Pnniculus nd Intertrigo 8 Pge 6 of 6
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