Aetna denying blood work....

So my doc had me do blood work and i got sent a bill for $230.00 in the mail. I called and they (Aenta) has deemed the blood work as "not necessary." And sent me this :



http://www.aetna.com/cpb/medical/data/200_299/0249.html


Clinical Policy Bulletin:
Inflammatory Bowel Disease: Serologic Markers and Pharmacogenomic and Metabolic Assessment of Thiopurine Therapy

Number: 0249


Policy

Aetna considers TPMT gene mutation assays (e.g., PRO-PredictR TPMT) or TPMT phenotypic assays (TPMT enzymatic activity, e.g., PRO-PredictR EnzAct) medically necessary prior to initiation of 6-mercaptopurine or azathioprine therapy. Only one genotypic or phenotypic assay of TPMT activity is necessary per member per lifetime. TPMT gene mutation assays and TPMT phenotypic assays are considered experimental and investigational for all other indications.

Aetna considers testing for anti-neutrophil cytoplasmic antibodies (ANCA), anti-Saccharomyces cerevisae antibodies (ASCA), anti-outer membrane porin C (OmpC) antibodies, anti-CBir1 flagellin (anti-CBir1) antibodies, and I2 antibodies experimental and investigational to diagnose inflammatory bowel disease, to distinguish ulcerative colitis from Crohn's disease, and for all other indications.

Aetna considers anti-smooth muscle antibodies (ASMA) experimental and investigational to diagnose inflammatory bowel disease or to distinguish ulcerative colitis from Crohn's disease [Note: ASMA may be medically necessary to diagnose autoimmune hepatitis].

Aetna considers 6-thioguanine nucleotide (6-TGN) and 6-methylmercaptopurine nucleotide (6-MMPN) (e.g., PRO-PredictR 6MP / azathioprine, PRO-Predict Metabolites) experimental and investigational to determine therapeutic direction and monitor response to 6-mercaptopurine and azathioprine therapy and for all other indications.

Aetna considers fecal measurement of calprotectin experimental and investigational for the management of inflammatory bowel diseases (e.g., Crohn's disease, ulcerative colitis) and other indications because its clinical value has not been established.

Aetna considers NOD2/CARD15 genotyping experimental and investigational because its clinical value has not been established.

See also CPB 341 - Remicade (Infliximab) (for measurements of serum levels of infliximab and antibodies to infliximab), and CPB 715 - Pharmacogenetic Testing.



There is a little more background information in that link. What does it all mean ? I am going to bring to my Doc but she said that i could also appeal it if i wanted.

I printed everything out and am going to show it to my doc on my next appt which is coming up. When the lady on the phone said "that blood work wasn't needed" I interrupted her and said "excuse me! Are you a doctor!?" She stopped talking and said she would email me the reason and we ended the call there.

I agree with Eva Lou. Insurance companies sometimes pull this kind of BS when you use a lab they don't like or a hospital outpatient lab. If it went to a preferred lab they might have just paid.

I had this happen to me and changed doctors because I really felt the doctor sent my blood work to his expensive hospital lab knowing full well I would get socked with a huge bill. He and all his employees are on the same plan as me. It took me 9 months of fighting to get the insurance to pay. It wasn't worth the nightmare.

It seems Aetna will cover one TPMT test because it is classed as medically necessary before starting thiopurine drugs but all other tests mentioned are classified as experimental and therefore not covered.
If diagnosis is clear-cut from biopsy some of the other test may not be required but 6TGN/6-MMPN and calprotectin are useful for directing correct treatment - they are new but should not be classed as experimental.
If you are on aza or 6MP I would recommend pushing for 6TGN/6-MMPN because there are several pathways for metabolising thiopurine drugs and even with a TPMT result certain individuals can be on an ineffective dose, or building up toxic levels of 6-MMPN.
Sue

I just had that done, my GI had to send a grant to the government, and I was approved. After that I have not had to pay for anything. This is in Canada btw. Not sure how it works in the states.

Hi. I'm new here. We're at our wits' end over this business. Aetna is denying the Prometheus claim. My son's not on Remicade but every GI we've seen insists it's necessary for the azathioprine. Has anyone successfully fought this?

I don't see how they can say repeated TMPT is not necessary. I had to have mine checked multiple times because I was not able to get into the right range.

Folks, 85% of the future growth in the ballooning US deficit is from medicare/medicaid, and medical inflation rates run 3x as fast as general inflation- someone has to pay for all of this and right now it is future generations. I accept that insurance isnt going to cover everything. I pay for tons of tests out of pocket. But I share your pain- I had a bunch of stool tests and allergy blood tests done recently that I knew were uncovered and it was still major sticker shock.

I am afraid the coverage by private insurers like Aetna, and the medical cost inflation of the privately insured population have no incidence on the US deficit or future generations.

Insurers do this because they can, and because a lone sick person can hardly fight the system alone. As a young person's disease UC exposes the flawed US medical system in all its ugliness. A youngster becomes uninsurable before having had a chance to have transitioned from his parents plan to his own.

Had the same problem. I took it to the doc secretary which called and took care of it.