Aetna Exclusion Help

I've been reading the posts on this board for a while now but this my first post.

My insurance is Aetna but my employer has an exclusion on our policy for WLS.   I did all the requirements anyway and my surgeons office applied.  I was denied.  We appealed.  I was denied again.  My denial letter states that WLS is not covered and they only cover procedures that are medically necessary.  We appealed again with letters from my PCP and GYN that say that WLS is medically necessary as treatment for my hypertension, chronic back pain, etc. I just called and they said I am still denied.  They said they are sending me another letter with my options for third appeal.

I was wondering if anyone has any success with appealing an exclusion or if I just need to give up and go to Mexico.

Thanks for you help,

Jill

Jill:

First and for most NEVER GIVE UP< NEVER < NEVER < NEVER.

If you are going on your third appeal, the first peace of advice is I would find out what Aetna considers medical necessity. Then get together with your dr to make sure you have any and all
acceptable reasons listed.  Find out what state insurance department regulates your policy.
and what laws your state has regarding surgical treatment for obesity.   It may get to the point where you are entitled to an idependent medical review.  IF that happens and the review board decides that your surgery is medically necessary then Aetna is required to follow thier decission regardless of what they have said in the past.


Good luck


and I am in the appeals process with UHC for the same reason.

Zells_lori is 'abuddingrose'

My company switched to Aetna effective 1/1/9.  WLS was not included in my company policy either.  I talked to my benefits coordinator in HR and he said it wasn't excluded it on purpose.  Long & short, WLS was added to our plan, it did take several weeks for the rider to go into force. The thing that tripped me up at the moment is the fact Aetna wants 90 days continuous Nutritionist supervision which means they want 4 total visits.  If you haven't already done so, talk to your benefits coordinator at work.