Aetna follows one simple logic to deny the claims as not medically necessary regardless of any supporting records the clinic may send. Most of the time Aetna’s insurance rep will not explain why they consider the claim to be not medically necessary.
Rule 1 : If no improvement is documented within the initial 2 weeks, additional chiropractic treatment is considered not medically necessary unless the chiropractic treatment is modified.
Rule 2 : If no improvement is documented within 30 days despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary.
Rule 3 : Chiropractic care in persons, whose condition is neither regressing nor improving, is considered not medically necessary.
Why updating initial date of treatment is so very important when the care is closed and new care is started after few months for a new condition ?
If the date is not updated, Aetna will assume that treatment is still being given for the illness that occurred several months before. Say for example if the initial treatment date is 1 year old, it proves that patient’s condition is not improving. If provider’s send records proving that the condition is improving, it is in contradiction with what is sent in claims because a treatment that improves patient’s condition does not require one year to cure.
