Why Aetna Denies Epidural Steroid Injection
Exceeds frequency limit (usually 3 per year per region)
Conservative therapy not documented
Prior injection did not provide documented relief
Know Aetna's Criteria
Aetna uses their own Clinical Policy Bulletins (CPBs) and InterQual criteria. CPBs are publicly available and numbered.
Key policies to know:
- Clinical Policy Bulletins (CPBs) are publicly available and numbered
- Uses eviCore for radiology and cardiology prior auth
- Known for detailed, evidence-based CPBs with specific criteria
- Precertification list updated annually
Building Your Medical Necessity Argument
Document radicular symptoms correlating with imaging
Note percentage and duration of relief from prior injection
Show failure of oral medications and PT
Reference imaging confirming nerve compression at the targeted level
P2P Call Tips for Aetna
Reference the specific CPB number and criteria being met
Aetna CPBs are very detailed -- read them before the call
Address each specific criterion in the CPB during the P2P
Aetna medical directors are typically receptive to guideline-based arguments
Guidelines to Reference
- ASIPP Guidelines for Interventional Pain Management
- NASS Coverage Recommendations for ESI
Relevant CPT Codes
Specialty: Pain Management / Anesthesiology
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