Aetna Denial for Lapband fills
Has anyone successfully appealed Aetna's denial for Lapband fills? I called Aetna before I had lapband surgery and specifically asked them "according to my policy are my fills covered?" They said they were, no problem. Well, now they're giving me two answers. This one, and another one that says my surgeon agreed not to be paid for this procedure. I'm getting the run around. I have a band that's costing me a fortune to maintain and it's ridiculous that they approved the surgery, but now won't cover a fill? That's what makes a band effective.
Here is the letter I received:
This is in response to your claim question on you for June 4, 2007 for
the amount of $875 from Dr. Carter.
This claim was denied, as it is not a covered benefit. The code
submitted is S2083; which is an adjustment of gastric band diameter.
We determine coverage based on your plan benefits and clinical criteria.
For details on clinical criteria, see Clinical Policy Bulletins #0157,
which can be found online at www.aetna.com:
- Select Members: public information
- Next select Health Coverage Information
- Then Clinical Policy Bulletins.
You are entitled to a review (appeal) of this benefit determination if
you have questions or do not agree.
To obtain a review, you or your authorized representative can submit a
request in writing to the Appeals Resolution Team address shown below.
Your request should include the group name (e.g., your employer), your
name, member ID (or Social Security number) and other identifying
information, and any comments, documents, records and other information
you would like to have considered, whether or not submitted in
connection with the initial claim. Your request for review of the
adverse determination must be communicated, mailed or delivered within
180 days following receipt of the explanation of benefits letter.
Send your written appeal to:
Appeals Resolution Team
PO Box 14463
Lexington, KY 40512
If you have questions, you can reach Member Services by logging on to
www.aetnanavigator.com and select "Contact Us." You may also call the
toll-free number on your member ID card.
Sincerely,
Internet Response Team
Aetna
10908282
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