Aetna hmo approval!!--texas

[beTHEchange 0]

I GOT MY APPROVAL FROM AETNA TWO DAYS AGO!! I actually called Aetna with a reference number my doctor's surgery cordinator gave me and they said it was still in pending status but it said "approval all". I was like yessss. Haha, I called back the next day, and it was completed--The information was sent from my doctor on the 18, and on Monday, it was approved. I did the 3 month diet. I'm 23, a mother of a one year old little boy. I've been overweight most of my life. Right now I'm at 324, and I'm 6'1. My BMI is 43. When I did the two year of weight history, I only submitted 3 sets of weights; I don't know what problems people had with Aetna approvals, but I was approved right away. Good luck to everyone. If anyone has any questions about my process and they have Aetna feel free to ask me. By the way, this is my first post, consider this a introduction too. haha!

[btrieger 21]

Congrats!!

When's your surgery and who's doing it?

[beTHEchange 0]

Thanks, I actually haven't scheduled surgery yet. I am still waiting on the official approval letter in the mail; the representative at Aetna, said it would take up to 5 -7 business days, so I'm still waiting. I'm in nursing school in Wichita Falls, so I'm trying to have it scheduled Spring Break which is the week of the 15th in March! I'm too excited. Dr. Hamn, in Plano is going to do it.

[meandtheboys 8]

Congrats on your approval. Sounds like it was pretty straight forward and that's how it should be. I was banded on 1/27 and am still learning, but confident that it was the best decision for me! I wish you tremendous success and and flawless surgery process. Best, Loryn

[leroyspuds 0]

Aetna approved me within a few days of my doc submitting the paperwork. I had surgery on 2/22/10. Though my BMI was less than 40 I have sleep apnea, so they qualified me. I did the three month nutritionist and exercise visits. It was easier than I thought. Aetna assigned a bariatric nurse to my case and he makes regular calls to me to find out how things are going. I must say Aetna has been pretty good to me.

[beTHEchange 0]

Okay, so I just got my letter yesterday; and I'm terribly disappointed. Apparently, I got DENIED! My sisters and mom, say it's not a denial letter on the SURGERY, but on the type of anesthesia the doctor wants to use. I will type in quote exactly what the letter says, and can you guys please give me some advice on what I need to say to the insurance company. Three representatives have told me I was approved, but now I get this letter...here is what it says...

Coverage Decision For:

3/10/2010-3/10/2010 UNLISTED PROCEDURE ABDOMEN PERITONEUM AND OMENTUM 1 Time (s)

Coverage for this service has been denied for the following reason: After review of the information received, the specific circumstances of this member and Aetna's Clinical Policy Bulletin: Anesthetic Infusion Pumps, coverage for on-Q pain pump and maracaine block is denied because Aetna considers infusion pumps for intralesional administration of narcotic analgesics and anesthetics experiemental and investigational because of the effectiveness of these pumps has not been demonstrated in well-designed clinical studies in the peer-reviewed published medical literature. Therefore, this, service is considered experiemental or investigational and not covered under the terms of the plan.

Then it says the EXACT same paragraph under this

Coverage decision for:

3/10/2010-3/10/2010 INJ ANES AGENT OTHER PERIPHERAL NERV OR BRANCH (CONSIDER AS TOS 04) 1 Time (s)..

please help me, im so discourage.

well guys im headed to church to pray about this now. if anyone has any advice, or any knowledge of this please help me out.

[btrieger 21]

I agree with your mom and your sister. Talk to you surgeon's office tomorrow and see what they think.

[beTHEchange 0]

What do you think that letter means though? In your honest opinion.

[btrieger 21]

What do you think that letter means though? In your honest opinion.

I think that they don't agree with the anesthesia. Your surgeon's office will be more familiar. Give them a call tomorrow morning. They probably got a copy of the same letter.

[beTHEchange 0]

Thanks, I'm just so anxious and nervous at the same time. I've been praying since I've gotten the letter. I've done everything right and to the T, so I would hate to not get the surgery due to the disagreement in anesthesia. BUT, the Dr's I go to, don't handle appeals, that I have to go through the "process of appeals" so I don't know what to do. I'm a mess. I guess I will start with Aetna, document what they say, then call the doctor. SOMEBODY TELL ME TO BE CALM. ahah.

[btrieger 21]

A lot of us have Aetna and have been approved. Your anesthesiologist will just have to use an accepted method or your surgeon can use a different anesthesiologist.

[LeighaMason 19]

Relax, everything will be fine, don't worry, your doctor isn't the only doctor in town and that isn't the only anesthesiologist. I don't think its a "no" I think its a "change your plan". If that doctor wont help with appeals someone else will. Too many people get this done with insurance.

And I also don't think you will need a pain pump after surgery anyway. I was in the truck on my way home (2 hour trip) less than 3 hours after I went in to surgery.

[DrHekier 0]

I wouldn't worry about it. It looks like someone submitted for approval for an infusion pump, which is not commonly used in Lap Band surgery and a nerve injection which is never used.

This seems to have nothing to do with your surgery.

Congrats!

Okay, so I just got my letter yesterday; and I'm terribly disappointed. Apparently, I got DENIED! My sisters and mom, say it's not a denial letter on the SURGERY, but on the type of anesthesia the doctor wants to use. I will type in quote exactly what the letter says, and can you guys please give me some advice on what I need to say to the insurance company. Three representatives have told me I was approved, but now I get this letter...here is what it says...

Coverage Decision For:

3/10/2010-3/10/2010 UNLISTED PROCEDURE ABDOMEN PERITONEUM AND OMENTUM 1 Time (s)

Coverage for this service has been denied for the following reason: After review of the information received, the specific circumstances of this member and Aetna's Clinical Policy Bulletin: Anesthetic Infusion Pumps, coverage for on-Q pain pump and maracaine block is denied because Aetna considers infusion pumps for intralesional administration of narcotic analgesics and anesthetics experiemental and investigational because of the effectiveness of these pumps has not been demonstrated in well-designed clinical studies in the peer-reviewed published medical literature. Therefore, this, service is considered experiemental or investigational and not covered under the terms of the plan.

Then it says the EXACT same paragraph under this

Coverage decision for:

3/10/2010-3/10/2010 INJ ANES AGENT OTHER PERIPHERAL NERV OR BRANCH (CONSIDER AS TOS 04) 1 Time (s)..

please help me, im so discourage.

well guys im headed to church to pray about this now. if anyone has any advice, or any knowledge of this please help me out.

[beTHEchange 0]

Okay guys, an UPDATE! So, I talked to the office mgr and she told me to "disregard" that letter about the On-q pain infusion pumps and that had nothing to do with my surgery. I had to go through the run around with this doctor's office, because the clinical coordinator was still "sick" and they "didn't know when she would return" well I'm sorry honey, but I know SOMEBODY in that office, knows her job and can handle it. It's funny how when you give a little attitude and ask for higher authority people tend to act differently. So finally my surgery is scheduled for March 17th at 730AM! Tomorrow, I go for my preop tests, and then I go on the 16th to pay, which is a total of $60. 35 for the speciality copay, and 25 for some book they want me to have. But before all of this, the clinical coordinator called today, after she checked my insurance benefits and told me that I would pay 35, and then 25 for a book, and then 250 for the "Assisted Surgeon" "INCASE MY INSURANCE DIDN'T COVER IT". I'm what? Me and my mom, and sister's just thought this was unethical and absurb. I have NEVER had to pay for this doctor that was out of network "incase aetna didn't cover it". I abruptly called Aetna, and the representative, said No, I am only liable for my specialty copay of 35. That if the participating facility and doctor, were using a surgeon who was not in network, for them to call provider services to establish an authorization for them to be paid. I called the clinical coordinator back and told her exactly what I had been told. She actually seem to catch an attitude, and say "well when you get that 8000 bill you need to call that representative back, this is because 9 out of 10 times the insurance doesnt pay the out of network doctor" Bull****. I've used out of network doctors before and Aetna has always covered it. Anywho, she proceeded to say, well we will tell the doctor that you do not want to pay the 250 and see if he will still go on with your surgery or not. I said fine. She called back approximately 45 minutes later to tell me, "me , the office mgr, and the doctor have decided to go ahead and waive the 250 fee for you this time". And in my head I'm like I'm sure you will. Yall are not about to turn down all this money for 250, because it would have been just as easy to find another doctor with an assisted surgeon ALL IN NETWORK! UGH, so stressful, but finally all is good. Surgery is set, I know exactly how much I'm out, so 13 days and counting.

[DrHekier 0]

In your doctor's defense, in my experience Aetna is one of the worst payors for Lap Bands and we physicians never know what they will do.

I once had to wait 9 months until I got paid by Aetna for a LAP-BAND®, and of course this was pre-authorized by them in the first place. My biller was calling them every few days for several months and getting nowhere. Only after I intervened and started calling every few days for a couple of weeks, did they relent and agree to pay.

A lot of patients aren't aware of the hassles that the doctors office goes through to get paid. I don't know the specifics of your situation, and I admit I am biased, but I have to take the side of the doctor's office over the insurance company. Especially Aetna. Even when they say they pay, they might take many many many months.

Most importantly, congrats on your impending LAP-BAND®!:smile2: