Aetna

Hello...wondering if anyone had experienced a second denial from Aetna PPO,  I have been working with the Obesity Law and Advocacy Center and they just informed me they received a verbal confirmation that  Aetna denied my first level appeal.  The Center and I are waiting for the letter indicating the reason for the denial...Needless to stay I am disappointed but there is always the second level appeal (not sure what that consists of...).  Please tell me there is someone out there that received approval on their second level appeal!  I have been on this WLS journey for nearly a year and I am a bit frustrated.

Thanks for listening.

Kathie

I work for Aetna... don't hate me for admitting that.  I do NOT work in any department that could help with the appeal.  However, I do have some information for you.  Have you checked out the Clinical Policy Bulletin that goes over what is required for the surgery? Do you meet all the criteria?   Also, is it your EMPLOYER who EXCLUDES the surgery or do they allow it based on if you meet the criteria.  

This is a link to the policy.  Read it thoroughly and make sure you meet all the criteria and also that your employer does not exclude it.  If you have any questions, I can try to help you answer them.  But again, I do not work in the precertification or appeals area, so I would not be able to access any of your personal information.

www.aetna.com/cpb/medical/data/100_199/0157.html

I have AETNA PPO and experienced no issues with getting approval on the 1st try.  Now that was over 2 years ago, so its possible things may have changed.
Couple of thoughts that may be contributing to their denial stance:
   Do you meet all of the criteria? ( I.E. your BMI and co-morbidities)
   Is your surgeon participating with AETNA?
   Is your surgeon part of a Center of Excellence?
If the answer to any of the above is "no", than that could be the reason.
   Does your individual plan have a WLS exclusion?
This would be from your employer who purchases the insurance policies and therefore has a direct say in what will and will not be included in the policy.  If there is a WLS exclusion, that translate to cold hard money....you are not paying for WLS coverage and if you are not paying for it, they will not provide it.
Let us know what the reason for the denial is and perhaps we can come up with some advice.