Question:
Aetna's "new" policy...

I have Aetna HMO small group in Maine and have just been given a surgery date of May 15th. I have been in this process since August of 2005. My plan covered the surgery supposedly until my company renewed our policy plan in November. Now they are telling me that unless my company purchased a "rider" for WLS then they won't cover it. My company did not purchase the rider and are telling me they were never told about this policy change. I looked up my plan details and surgical treatment for obesity is under the exclusions BUT it says it's excluded UNLESS pre-authorized by HMO. Now, for the real question...what does that mean, and can I fight it and win?? **(SIDE NOTE)I have been documenting every conversation I've had with them and I was told on Nov. 2nd that it was covered under the new plan, and then on Jan 24th they said it wasn't and gave me the rider line.    — kmack (posted on February 16, 2006)

February 16, 2006
just the sentence 'surgical treatment for obesity' is WRONG. NO ONE has surgery for obesity - its Morbid obesity (TWO seperate diagnoisis), But the bottom line is I would go talk to your HR person and have them talk to Aetna directly to find out whats what. If they insist then appeal on the grounds that your getting surgery for morbid obesity and their 'excuslsion doesnt mention it being excluded. :) good luck
   — star .

February 16, 2006
Kelly YOU ARE VERY LUCKY!! HMO's have to authorize surgery, not the insurance company. Therefore, since you have an HMO, just get your doctors group/medical group to authorize your surgery as being a medical necessity. There is no legal AETNA can deny an HMO authorization. So you're in the clear (well I can't guarantee any thing) if your HMO says its a go and is medically necessary.
   — Meghan R.

February 16, 2006
OH my god, I posted this same question a few weeks ago, I quoted the AETNA info just like you did. I was denied by my medical group and was devastated. I had the HR person and my husbands work call AETNA and get it straightend out. PLEASE do this as my denial was reversed within a few days! That statement is not clear at all....except when preauthorized by HMO.....so get it straight thru you or if its your husbands work. I have a surgery date now so dont give up. Keep on using the term "medically necessarey" GOOD LUCK< keep me posted!!
   — jomamma