Is it common among insurance carriers to not cover a 20-week ultrasound or do we just have a bad plan?

Is it common among insurance carriers to not cover a 20-week ultrasound or do we just have a bad plan?
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#1

So my hubby and I just found out that our insurance (Aetna) doesn’t cover the 20-week ultrasound unless it’s “medically necessary”?! We just want to know if we’re going to have a boy or a girl. Does that mean we’ll have to pay out of pocket for the ultrasound?


#2

Any medical care must be "medically necessary", otherwise no insurance will cover it. In order to get this covered, you need to take several steps:

1. Did the doctor or facility get pre-certification before doing the test? This is simply proving medical necessity to the insurance.

2. Call your insurance to determine why they did not pay the claim.

3. Write an appeal, which explains why your ultrasound should have been paid, enclose supporting documentation to support the facts in your letter. Send it certified mail to the insurance appeals address.

Good luck and please contact me at 732-640-1006 if you have any additional questions or would like an advocate to help you. Good luck.


#3

I have seen this denial in the past and the reality is that Aetna does cover 20 week Ultrasounds.
You might want to check the level of coding used for the ultrasound performed and to see if the documentation meets that level of coding. What I have seen in the past is where the provider is billing with a more complex ultrasound than what is medically necessary.
If you can’t get this denial overturned in appeal see if the provider is willing to work with you on the balance. It’s unfair that they did not disclose to you that it would be denied and let you make an informed decision.
If you need assistance with this please reach out!
Best of luck to you!
Cheryl Welch, MBA
Hudson Valley Medical Bill Advocates.


#4

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