I received a email from a client that had a question on a claim inspector edit:
Aetna has a infertility policy CBP # 0327 at the website below that covers J0725 - Injection, chorionic gonadotropin, per 1,000 usp units. The Texas House & Senate passed a bill that covers certain fertility medications & services. Can you review this for me with the AMD Edit # in the screen print I added below. Hopefully, these questions are not off the sleeve to much for you. I am out of my element with the time change and all. Thanks C.M.
- Human chorionic gonadotropin (hCG) (A.P.L., Novarel, Pregnyl, Profasi HP, Ovidrel, Chorex, Choron)
- Human menopausal gonadotropin (hMG) (menotropins) (LH and FSH) (Menopur, Repronex)
- Recombinant follitropin products (recombinant FSH) (Follitropin alfa (Gonal-F); Follitropin beta (Follistim)
- Urofollitropin (human FSH) (Fertinex, Bravelle).
Gonadotropins are considered medically necessary for the following indications:
- Women with WHO Group II ovulation disorders such as polycystic ovary syndrome who do not ovulate with clomiphene citrate or tamoxifen. (See appendix for WHO classification of ovulation disorders.)
- For use in pituitary down-regulation as part of in vitro fertilization treatment (Note: coverage of gonadotropins for this indication is limited to plans that cover advanced reproductive technologies. Please check benefit plan descriptions for details.)
- Pulsatile administration of gonadotropins are considered medically necessary for women with WHO Group I ovulation disorders (hypothalamic pituitary failure, characterized by hypothalamic amenorrhea or hypogonadotropic hypogonadism)
- Clomiphene plus gonadotropins may be considered medically necessary in women who do not ovulate using clomiphene alone.
How to resolve this question:
The issue - claim was scrubbed through a claim inspector software (Ingenix) and kicked out for Aetna claim that was billing with a J0725. This was my response to her email:
Your information is extremely well researched. The screen shot shows the J0725 diagnosis code as 629.9 (unspecified disorder of female genital organs). The edits says the diagnosis code associated with the J0725 is not normally associated to this procedure code. The documentation you sent me (thank you again for your thoroughness) does not list 629.9 as being a “covered” diagnosis code.
Ingenix is notifying you that this procedure may be rejected due to a “possible” invalid diagnosis code. It doesn’t mean you will not get a payment but they are warning you of the possibilities. Since you have a listing I would recommend following up with your provider and review this list of DX codes and identify what he/she would like to do.
Ingenix Edit Rule Code: 73065080 None of the ICD-9 CM Diagnosis Codes on this claim line are frequently associated for procedure J0725.
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