Aetna denied my 20-week fetal anatomy ultrasound. Best next steps?

[u/ruthlessrasmus]

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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