Denied by Aetna

Being denied by Aetna isn't really a shock to me. I knew going into this that it would be an uphill battle, however, I called them yesterday to check on the status and was told I wasn't showing up on their computer. Now, I had e-mailed them and had been told that they had forwarded my file to patient management on 7/5 so not showing up in their computer made me be a bit concerned that someone had lost it. I decided after talking with them on the phone to e-mail them again to see what was going on. Today I received the e-mail response that they had denied me on 7/26 (the very day they said I wasn't in the computer) and that the reason was that it appeared that the medical information provided by my doctor did not warrant this procedure, however, there would be more information in the letter that I would receive. Has anyone ever had this as a reason? I cannot imagine this as I had a letter from my PCP, surgeon and cardiologist as well as notes from all three. I have a high BMI and co-morbidities for crying out loud and they say the surgery isn't warranted????? Beth

Beth, I never heard anything about a doctor being warranted. What does all of this mean. All I know is, Aetna will lose your papers. They lost my first appeal packet and had the nerve to ask me why did I mail it to that address. I submitted a second packet but mailed it directly to someone in member services. They got it to the right person. After phone calls every day (really), I was approved. Get ready to fight a good fight. If you need help let me know.

Hi Krecia, After MANY phone calls and finally talking to someone in case management with Aetna, I found out that they had called and spoke with my surgeon's insurance person and that she was given the information that was needed for my approval-they told me to call the surgeon's office. Now, I don't mind calling the surgeon's office but it really irks me that NO ONE at Aetna could tell me what they told the insurance person in my surgeon's office. Its like I don't exhist or I'm too stupid to comprehend what they are saying. Like a big mystery and cover up and that makes me angrier than anything else! Made the call to the surgeon's office and found out that what they mean is my PCP didn't document fully in her notes my diet attempts for the past two years. You see, my husband's employer is the carrier for our policy and they put a stipulation in that they require 2(!) full years of the documented diet attempts vs the 6 mos. others have to have. I actually have 4 years of documented diet attempts and I don't know why, since I highlighted all 4 years of it, they can't see what was going on. Aetna suggested my PCP appeal on my behalf and have a peer to peer review with the doctor that denied me. Some tell me this is a good sign but I'm not so sure of that. My PCP supports me 100% and agreed to do the peer to peer review but I don't know when she intends to do it. It can't be soon enough for me! Beth

This is very common unfortunately. In fact, you may not be denied and should keep calling until you receve a letter. They are all tending to do this now either intentionally or not, but they have no idea what they are doing and each person you get on the phone has a different story. Keep pressing until you see a letter, and if you are fully documented like you said appeal again. Good luck Gary Viscio www.obesitylawyers.com