Health Insurance Coverage of Labs and Meds

[tm999]

Hi,

I have Aetna insurance (PPO). For various reasons, I'm not on medicare. The claims I have submitted for my lab work and medications have been covered; I think Aetna may not realize that I am receiving treatment for ME/CFS. However, I have not yet submitted claims for my specialist office visits (the receipts include the chronic fatigue diagnostic code), which I am afraid to do because I'm afraid it could become more clear to Aetna that I am receiving treatment for ME/CFS, and as a result, Aetna could start denying my lab and medication claims. Should I be concerned? Does anyone have thoughts/related experiences?

 

[Gingergrrl]

I don't know if this will be helpful because each situation dealing w/insurance is so complex and nuanced. But in my experience, the key factor in getting lab work, blood tests, medications, IVIG, etc, covered was based on the diagnostic and billing codes submitted by the doctor's office, hospital, infusion center, etc.

It wasn't so much what I was being treated for vs. which billing codes were submitted to LabCorp, Quest, or whichever entity was conducting the tests or providing the treatment. I've had several different insurance companies (at different times) during the period that I was sick (Medicare and private insurance through my former employer) but in all cases, what was critical in getting Prior Authorizations, reimbursements, etc, were which specific diagnostic & billing codes were used.

I hope this made sense and if it didn't, I can try to explain it better

 

[tm999]

I don't know if this will be helpful because each situation dealing w/insurance is so complex and nuanced. But in my experience, the key factor in getting lab work, blood tests, medications, IVIG, etc, covered was based on the diagnostic and billing codes submitted by the doctor's office, hospital, infusion center, etc.

It wasn't so much what I was being treated for vs. which billing codes were submitted to LabCorp, Quest, or whichever entity was conducting the tests or providing the treatment. I've had several different insurance companies (at different times) during the period that I was sick (Medicare and private insurance through my former employer) but in all cases, what was critical in getting Prior Authorizations, reimbursements, etc, were which specific diagnostic & billing codes were used.

I hope this made sense and if it didn't, I can try to explain it better

Thank you so much for your detailed response. This is very helpful!

 

[Mary]

@tm999 - @Gingergrrl is right. For your lab work to be covered, your health care provider had to submit a diagnostic code or codes that Aetna accepted. So I would assume that your doctor's office used the same diagnostic codes for your lab work as they are doing for your specialist's visits. So I don't think you should have a problem getting the specialist visits covered. But since you have questions about this, I'd call the billing office and ask about the codes used for your lab work and verify if they are indeed the same as those used for the doctor visits. I can't imagine they would be different and if they are different for some reason, I'd try to find out why.

 

[Gingergrrl]

Thank you so much for your detailed response. This is very helpful!

I'm glad that what I wrote made sense (and I was not sure )!