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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u/[deleted] Jun 13 '25

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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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