r/HealthInsurance • u/ruthlessrasmus • Jun 13 '25
Employer/COBRA Insurance Aetna denied my 20-week fetal anatomy ultrasound. Best next steps?
Hey all, pregnant woman over here dealing with an Aetna denial. Fun times. They denied my fetal anatomy ultrasound (CPT 76811) as experimental / investigational because I have a routine pregnancy (no suspected genetic abnormalities). My hospital, and many others, consider the fetal anatomy scan part of routine prenatal care. Every pregnant person I know has gotten one, and in fact it’s considered THE ultrasound because you get to see their entire anatomy and it’s really exciting. I thought nothing of it until the denial.
Aetna does not consider this scan medically necessary unless there are suspected abnormalities (https://www.aetna.com/cpb/medical/data/100_199/0199.html Ultrasound for Pregnancy - Medical Clinical Policy Bulletins | Aetna). I looked at my medical records and it seems like my hospital coded it correctly, but now what? It’s around $3K patient responsibility. Should I try to convince my hospital’s billing department to recode the claim to reflect a more basic fetal anatomy ultrasound (CPT 76805)? Going in to the scan, I knew it would be a routine anatomy check, again, since I don’t have suspected abnormalities. Any advice or guidance would be much appreciated, thank you!
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Jun 13 '25
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u/Ill_Safety5909 Jun 13 '25
^ this. FYI they still won't cover it all. They will only discount it if you aren't at your deductible and OOPM. I think I paid $400 for mine. And I have a high risk pregnancy. It's not considered preventative care. Which blows my mind.
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u/Penny0813 Jun 14 '25
I think there’s some miscommunication around the word “covered” - something is still a covered service even if you still have to pay deductible and OOPM. The difference is that a non covered service wouldn’t go toward your deductible and OOPM. Just clarifying for those reading along, not trying to correct you or anything!
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u/Ill_Safety5909 Jun 14 '25
Thank you. I more meant it's not preventative. Not that it's not covered at all.
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u/TheBandIsOnTheField Jun 13 '25
I am on Aetna, mine was completely covered.
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u/flopjobbit Jun 14 '25
Every employer has a unique contract with an insurer. Its one a 1:1 comparison .
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u/ruthlessrasmus Jun 13 '25
For the code 76805?
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u/throwawayeverynight Jun 14 '25
Cider here, the coding department at the hospital will not down code a procedure just to get it cover , that’s insurance fraud. The CPT code itself isn’t the problem, the problem is the DX code that was used to link to this procedure for meet Aetna medical necessity guidelines. If your pregnancy is routine and it was billed with a diagnosis code in the range if Z 34.xx that clearly states it a supervision of routine pregnancy therefore it’s not in the list of medical necessary diagnoses codes that are covered.
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u/Any_Broccoli8759 Jun 14 '25
True. They are not 100% covered. I don't even remember what I paid for mine and I had them every week as I had gestational diabetes.
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u/Concerned-23 Jun 14 '25
False. 76811 is an anatomy scan but it is a more detailed scan to look for any suspected abnormalities.
The 76811 includes all of the components of the 76805, plus a detailed fetal anatomical survey.
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u/Concerned-23 Jun 13 '25
My anatomy scan was billed as 76811
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u/Any_Broccoli8759 Jun 14 '25
You likely didn't have a full anatomy scan or it was billed wrong. 76811 is only a limited view, not a full scan like 76805
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u/Concerned-23 Jun 14 '25
It was a full scan actually had to go to the hospital for it opposed to the OB. Actually just read the CPT and 76811 is more detailed. I hadn’t realized it got billed for looking for abnormalities. My husband was born with a heart defect, which means our child was at risk of a heart defect so we actually needed a more thorough scan
Edit: The 76811 includes all of the components of the 76805, plus a detailed fetal anatomical survey.
So I actually had a higher level scan than standard
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u/MrsSchoonover Jun 14 '25
This is incorrect. A follow-up growth/anatomy is 76816. The 76811 is for a detailed anatomy.
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u/Keddie7 Jun 13 '25
I don’t have advice for you other than to reach out to your provider directly. That’s crazy, I’ve never heard of a modern pregnancy in the US not given an anatomy scan. For many issues that’s the first real check they can do for them, that’s CRAZY to think you should have to skip it or pay 3 grand. (Which also seems like an outrageous amount for even a specialized ultrasound). That’s such an important scan, at least according to what my doctors have told me.
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u/Keddie7 Jun 13 '25
Looks like it was probably miscoded, like the other commentor stated. That would be on your doctors office to fix. Check this thread: https://www.reddit.com/r/pregnant/comments/neziua/20_week_anatomy_scan_not_covered_by_insurance/
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u/Concerned-23 Jun 13 '25
The anatomy scan was done to rule out amniotic band syndrome, confirm there is not single umbilical artery, confirm there are no markers for aneuploidy, and to rule out abnormalities.
The “anatomy scan” isn’t done to just see your baby and find out the sex. It is quite literally the scan they do to make sure the baby is developing appropriately and there aren’t any signs for shortened cervix, placenta previa, small for gestational age, osteogenesis imperfecta etc.
Your doctor’s interpretation should make it clear the scan was checking for those things. Then it is not experimental.
My anatomy scan report is like 2 pages long listing all the things they checked
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u/anxious_teacher_ Jun 14 '25
Are you supposed to receive the report?? My OB doesn’t have a patient portal so i haven’t gotten anything like that at all. Only bloodwork results from LabCorp
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u/Concerned-23 Jun 14 '25
I got mine, but my office uses MyChart so it went on there. I could read every single part of the body that they looked at.
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u/anxious_teacher_ Jun 14 '25
Wow that’s pretty cool. There are some advantages to go to a small mom and pop shop (well in my case, mom & daughter shop) but I guess I might be missing out on that stuff. But not sure I need to drive myself nuts reading the details instead of trusting the doctor when she it all looks good lol
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u/lavazone2 Jun 14 '25
Yeah, I trusted my “small shop” until a crucial MRI report got shoved into the middle of my chart without the Dr ever seeing it. That mistake delayed a proper diagnosis for a year. It required immediate surgery and solved all the problems I’d been having. I will now only use a Dr that has My Chart and I go over it with a fine tooth comb. Just found a new diagnosis from an ER visit 10 months ago, yesterday, that had officially been updated but the new info was never passed on to me. It is the diagnosis for what I’m going to the Dr for today,lol.
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u/Concerned-23 Jun 14 '25
I live in a large city. There really isn’t a mom and pop place, maybe if you do a doula and midwife that’s as close to “mom and pop”. The doctors all work under a certain hospital system.
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u/Outside_Ad_7262 Jun 13 '25 edited Jun 13 '25
They only pay for a basic scan the code you listed is for a detailed scan. Tell your provider they only pay for a basic scan and see if they can recode it as a basic.
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u/DoseofDee Jun 14 '25
As a medical coder I can say that once the test is performed they are not allowed to change the procedure code. If it was a detailed scan they would not be able to change procedure code as the scan was already performed. They can only change code/procedure prior to having exam.
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u/Jcarlough Jun 13 '25
Uh…sounds like she already had the scan?
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u/Impressive_Number701 Jun 14 '25
I'm sorry this probably isn't helpful but my anatomy scan just went towards my deductible so was around $200 fully paid by me. $3k is just so outrageously more expensive than anything I've experienced I wonder if this wasn't just a standard scan but something more in depth and that's why you're running into the denial.
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u/ADLovelace16 Jun 14 '25
It’s just so bizarre how everyone’s is so different. Mine was billed to Aetna and I have yet to meet my deductible and EOB shows $0.
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u/amedun Jun 14 '25
Aetna will cover a basic anatomy scan, not a detailed one. Unless you have a suspected fetal abnormality or other qualifying conditions. Maybe your provider will change the procedure code or referral reason? Its ridiculous. Aetna didn’t cover my 12 week NT scan because I got NIPT.
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u/Jcarlough Jun 13 '25
Looks like you got the answer you needed from your other thread.
Ultimately it’s up to your provider whether they will change the coding. Both codes may be valid for the service received. If they used the code they believe to be correct they may refuse to change it.
It could also be a new medical & billing coder who made an error.
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Jun 14 '25
This isn’t surprising. Back in the day ( way back), they were the only insurance that deemed MRI scans still experimental. Every other insurance had started paying them.
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u/Midmodstar Jun 14 '25
Was the claim denied? Or was the out of pocket cost because you have deductible to meet?
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u/Specific-You-4948 Jun 15 '25
Verify the diagnosis that was used when the claim was billed. It could be denied for that reason. The procedure code probably cannot be changed. Possibly the diagnosis can be changed. They process the claims using the diagnosis code as well for each procedure. Did they pay the provider portion of the claim? Both claims should both process and or deny. See what diagnosis was used on the professional claim. Both claims should process the same way. Call the billing department and ask for a diagnosis coding review. Aetna has many different policies, some may cover things that others may not. Check your policy benefits, to see if it a covered service. It might be that your policy doesn't cover this. Know your policy benefits inside and out. This way you can get them to cover it. Most policies should cover this, with the prenatal care. I'm IF it cannot be reprocessed because everything is correct. But, I doubt it.. then ask for a self pay discount. To lower the cost. You could also ask for a payment plan.
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u/Nan2Four Jun 13 '25
Did you sign something with the hospital that you would pay for services not covered by your insurance? If you did you will have to pay. Otherwise appeal the decision.
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u/CascadiaRiot Jun 14 '25
Why would it be in the best interest of population/public health for you to get something for which there is no indication?
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u/LeafySeadrag0n Jun 14 '25
My 20 week anatomy scan with my first baby revealed a fatal heart defect. Tell me what indication I should have been looking for to “justify” this scan?
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u/CascadiaRiot Jun 14 '25
I was in a similar situation at a 22w scan and it revealed something that made the pregnancy nonviable.
But…until we get a standardized (single payer) healthcare system where there isn’t churn (ie same entity is responsible for your health expenses for your lifetime), why would they pay for that? Because they pay to treat something early, they don’t get the benefit of the reduced cost of care in the future.
SINGLE PAYER NOW. Get profit out of healthcare.
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u/NewIndependence Jun 15 '25
Just to say ive had a baby in the UK and in the US - the anatomy scan in the UK checked only a few things compared to everything that was checked as standard on the US. It was like 10 minutes in the UK, I never recieved any results, and they didn't check any organs or anything. I was astonished at the fact my anatomy scan here took nearly an hour and that they checked everything.
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u/sjd208 Jun 14 '25
Wow, what a take. Even if it’s not the worst case/non viable pregnancy it can also reveal conditions in mother or baby that with this foreknowledge can be managed more safely/better outcomes (including preventing death of either mother or baby) and likely less expensively both at birth and aftermath than without that knowledge.
A few off the top of my head: placenta previa or accerta, shortened cervix, baby too small or too large, 2 vessel cord, serious abnormalities in the baby, markers for further genetic testing pre-birth.
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u/CartographerKey7237 Jun 13 '25
It's a routine survey anatomy scan lmfao they look every part of the anatomy around 20 weeks including but not limited to heart, lungs, kidney, spine, limbs, facial anatomy, amniotic fluid amount, uterus size, fetus size/weight, and more.
I'm more concerned you didn't know about this... I've had 2 because they were not able to view all of the vital parts of my baby's anatomy due to positioning. They are quite routine now.
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u/ZookeepergameNew3800 Jun 13 '25
That’s ridiculous. At my anatomy scan they found that my cervix was super short and opening already. I was rushed for an emergency cerclage surgery and gave birth at 36 weeks. Without the scan my baby would have been born around week 20 and wouldn’t be here. And that’s one of a thousand important things they could discover. Ultrasounds are absolutely harmless , btw. The radiation we have constantly today from our devices hits harder than such rare , safe screenings.
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u/BumCadillac Jun 13 '25
Just because you opted out of perfectly safe prenatal care, doesn’t mean anybody else should.
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u/NewIndependence Jun 13 '25
What? Ultrasounds are harmless, this scan is very important as it checks so much. Please speak to your health care professional about the risks and benefits. Honestly, it's complete negligence not to get it.
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u/Dombat927 Jun 13 '25
Do some real reading on all the stuff that can go wrong during pregnancy (peer reviewed real science). Then read what the ultrasound can detect and how very low risk it is. Just because you did fine without one doesn't mean it wasn't a gamble. It just means you were lucky. Not every one wants to take that gamble and not everyone gets lucky
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u/Dombat927 Jun 14 '25
If you can't think past "it went ok for me one time" then you have some serious cognitive issues. One person is not an appropriate sample size to determine what is in the best interest of everyone. If one person walked away from a jump off a 5 story building would you take that jump? Or would you think that one person was lucky as hell, but I would rather not talk that risk.
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u/Dombat927 Jun 14 '25
Lots of babies are born to drug addicts, some of them are ok. Doesn't mean it's ok to do drugs in pregnancy just because one lucky addict had a normal baby. One pregnancy is not an ok sample size.
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