** Aetna Healthcare Hell !!! Denied !!!

Aetna's requirements for WLS, I think, are extremely vague. One requirement that I missed as well as my surgeons office is the requirement for my family doctor to assess me before I go to a dietician and then again at the end. I thought my dietician did all of that but not so. OK, so I goofed. How do I rectify it. Well according to Aetna, you cann't. My family doctor wrote a letter, albiet one that I should have asked him to do at the start of my three month required diet, and my surgeon was told he could write the later letter. The person making the decision at Aetna, a medical director, in what Aetna calls a peer-to-peer discussion between my surgeon and this medical director, told my doctor to fax this information to him - which they did last Friday. Today, this medical director is off so another medical director picks up the faxed info from Friday reads it but not knowing what all was discussed last week with the other medical director DENIED my pre-cert. Unbelievable. Although I have not received the official denial letter, my doctors office told me that they did not want to accept my doctors letter since too much time has gone by. I started the diet last February, five months ago, and have been trying to get through the Aetna maze for the last three months. So my conclusion is Aetna must want me to do the three months diet AGAIN!!!!!! Or perhaps they want me to just go away. But will I do that Nooooooooooooooo!!! Jim

Jim, You deserve to be treated better! I know how difficult it is to meet all the "pre-cert requirements", and then to have them not follow their own guidelines ... very disappointing. I still believe that the insurance companies deny on the first few passes secondary to their hope that we will grow tired of the process. Insurance companies have no idea how long we've been dealing with the inconsisitencies in society secondary to MO. Stand your ground, keep great documentation of the interactions with Aetna...they'll get caught in their own loop at some point very soon secondary to their lack of following their own legal contract with you. Frequently the medical reviewer has little to NO experience with WLS I was going through the preauthorization, denied on the first attempt, when my surgeon called he was informed that a lap band would not be "helpful"...interesting...I am asking for preauthorization for a RNY!! My surgeon and I agree with him, a lap band is not going to be helpful for me! If only he had read the paperwork which was sent to his company... Hence, review process again! Maybe a letter to the reviewer explaining your personal experience, validate the surgery type and the list of "pre certification" items completed...and expectation for approval secondary to meeting the Aetna contract requirements for WLS? We may have to educate them one patient at a time. MaryG