Query: Aetna Medicare Challenges
As of 2022, we have had a problem with Aetna Medicare denying CPT 11055–11057. Is anyone else having this problem? We have several claims that have been denied under the LCD; however, the same codes were billed exactly the same way last year for the same patients and Aetna Medicare paid. Any input would be greatly appreciated.
John W. Lane, DPM, Maumee, OH
Response: MAPs (Medicare Advantage Plans) are required by CMS to cover the same items Medicare does, just not necessarily pay the same. That said, they should be covering this assuming the proper class findings are documented. I assume this is an Aetna problem and not a practice problem having the same coding on board. The location of the lesion could be a factor as well if billing for these codes and the nail care codes as distal lesions have been lumped in with nail debridements. I would appeal, speak with a provider rep, and if need be, ask for a peer-to-peer review.
Michael King, DPM, Nashville, TN
