aetna question on appeal

I was denied for WLS from Aetna back in May due to no evidents of a supervised diet... I just completed my 3 months of supervised diet and was ready to submit my appeal along with all my documentation.  I called Aetna to make sure I have clarification and was told I did not need to submit an appeal and was told my surgeon needs to call in for a pre certification.  This is the first time I’ve heard of this pre certification.  Has anyone every heard of this from Aetna ?   

 

 

A pre-certification is a request for approval for a given procedure. Ideally, before a doctor decides to perform a major (and expensive) procedure on a patient with health insurance, he or she will submit to the insurance company to get approval to render the service and as a guarantee of payment for the service if it is rendered under the guidelines that the insurance company has authorized.

The usual process to overcome a denial is to appeal. However, if what the representative at Aetna told you was correct, it seems as if you were not previously denied for the surgery, just perhaps put on hold. If that is the case, then all the surgeon has to do is to resubmit the corrected paperwork for approval this time, which is less of a formalized process than an actual appeal.

I would contact Aetna again and explain the situation to see if you get the same information. I would also contact your surgeon's billing office to see what type of response it originally received from Aetna.

I hope I was able to assist you.

Tanks Xavier,  I did call Aetna twice to make sure that gave me the same answer.  What I was not understanding  was the letter they sent me did not say anthing about pre-certification.