Aetna CO-97 Bundling Denials in Cardiology
Payment adjusted because the benefit for this service is included in another. Copy-paste appeal letter with documented overturn rate and attachment checklist for Aetna in Cardiology.
Verify before filing
Filing deadlines, appeal addresses, and policy criteria in this template reflect typical payer behavior at publication. Aetna updates policies frequently and plan-level rules vary by employer group, state, and line of business. Always cross-check the specific deadline and filing address on your EOB, and confirm current Aetnamedical-policy language through the payer’s provider portal before submitting an appeal. Overturn-rate language below reflects AAPC-reviewer consensus, not payer-published statistics.
When to use this template
Aetna CO-97 bundling denials in cardiology cluster around three patterns. First, EKG (93000) billed same day as E/M. Aetna bundles unless modifier 25 on the E/M demonstrates significant separately identifiable service. Second, stress test professional component (93016) billed without the corresponding technical component (93017) when the practice doesn't own the imaging equipment.
Attachment checklist
- Ordering provider note with clinical indication
- Prior workup or conservative-care documentation
- Payer medical policy reference citing met criteria
- Retroactive authorization request (if applicable)
Missing any one of these is the single largest cause of appeal denials. Build a pre-filing checklist before you submit.
Copy-paste letter template
Swap in your patient details at every [bracketed field]. Attach the documentation listed above. Submit within 180 days of the original adjudication.
[Corrected-claim cover letter] [Practice Letterhead] [Date] Aetna Claims Department Re: Corrected Claim. CO-97 Bundling Correction Member: [Patient Name] Member ID: [Member ID] Date of Service: [DOS] Original Claim Number: [Claim #] Correction: Line 1: 99214 (Office visit, established, level 4). Modifier 25 added to indicate significant separately identifiable E/M. Line 2: 93000 (Electrocardiogram, complete). Standalone billing. Clinical documentation supports separately identifiable E/M: "Patient evaluated for [chief complaint / additional HPI elements] beyond EKG interpretation. History, exam, MDM documented separately from EKG interpretation and findings. New prescription written for [medication], discussed [additional topics]." E/M note attached for review, demonstrating clinical work distinct from EKG interpretation. Corrected claim, frequency code 7. Sincerely, [Billing Manager]
Check the NCCI Modifier Indicator before appealing. Indicator 0 = absolute bundling (no appeal possible, change your coding). Indicator 1 = modifier bypass available with clinical support.
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Related templates
Same code, different payer. Or same payer, different problem
Want the full playbook for this scenario?
The complete playbook page covers why Aetna throws CO-97 specifically in cardiology, the exact fix workflow, filing deadlines, high-risk CPTs, and FAQs. Plus this same copy-paste letter.
Read the full playbookCommon questions on this template
How long do I have to file a CO-97 appeal with Aetna?
180 days from the initial adjudication date for most Aetna plans. Corrected claims (for administrative fixes like missing modifiers or auth numbers) have a different and usually longer window. Always confirm the specific deadline on the EOB for your claim.
What is the typical overturn rate for this denial type?
80+ percent with documented mod-25 support. Success depends heavily on documentation completeness and whether the clinical criteria in Aetna's medical policy are matched point-by-point in the appeal.
Should I file this as a corrected claim or a formal appeal?
CO-97 is typically a corrected-claim fix, not a formal appeal. Identify the specific RARC code on the EOB that pinpoints the element to fix, correct it, and resubmit with frequency code 7.
Can I reuse this template for other payers?
The structure works for any payer, but the filing address, deadline, and policy references are specific to Aetna. Check our other templates for payer-specific versions; we have 50+ payer/code combinations in the directory.
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