This story may prove to be instructive for anyone who manages to have their carrier's denial overturned on external review. I did just that, and was thrilled that Aetna was going to be forced to pay for my band surgery. Everything is scheduled and set--I thought. Last night I get a call from my surgeon's office telling me they'd like to postpone, since they can't seem to reach an agreement with Aetna on the rate for the operation. Aetna's offering a really lowball amount, claiming this is their "contracted amount" for the CPT code assigned.

Well, duh, I KNOW they don't even HAVE a "contracted amount" for this procedure, because they don't PAY for this procedure!! So now I'm calling the NJ Dept of Health and Senior Services to find out how to force Aetna to comply.

Stay tuned, and wish me luck!!

I'm giving Aetna the "stink eye" smiley for you! They are such jerks! I'm pulling for you though. Last week I sent my paperwork into the state of Michigan for an external review, so with the backwards intestines and exception debacle I'm sure the surgery will be approved. Lets just hope Aetna can come to an agreement on yours soon. Let us know what happens!

I had a talk with my guardian angel yesterday (that's my boss, the insurance genius), who gave me some good advice. (Anyone can PM me if you want to know more--I don't want to say too much in "public.")

Yesterday I spoke with a very nice and helpful person at the NJ HSS, who said this was a very unusual problem for them. Usually, when a decision is overturned, the plan in question has out-of-network provisions that can be put into play. But I have an HMO, so it's up to Aetna and its participating providers to reach an agreement.

My role is to put pressure on them to negotiate IN GOOD FAITH, and be sure they are not violating the letter or spirit of New Jersey's external-review regulations.

Anyway, I'll have some more to report on Monday. In the meantime, I refused to allow my doctor's office to change my date--we have until August 13 to make a "deal" and I know it can be done by then.

Fingers crossed!!

I finally got approved! I am so excited! As soon as I see the psychiatrist then I can schedule surgery! Aetna made an exception in my case because of my crazy intestines! Right now the soonest I will be able to have surgery is September 22! I'm so excited I can't hardly stand it!

:D

Oh my god!!! Congratulations, Ginger! I am so happy for you, and really thrilled to that someone at Aetna actually seemed to have a brain in this case. YAAAAHOOOOO!!!

All right, girlfriend! (I'm high-fiving you from NJ, just in case you can't tell.) :banana :banana

I guess I am a little confused. I have Aetna and lots of people have AEtna here in the forum and we were all approved for surgery. And in my company's policy with Aetna, it clearly says Lapband is covered. It took them a month to approve me, but others got approval in just a few days. During my process of waiting for approval Aetna even cut back it's criteria of needing a 5 year health history to just requiring a 2 year history as of June 8, 2008. I thought they were moving in the right direction and making it easier for those who came after me. I have Aetna Pos II. Perhaps the difference is in the type of policy or in the particular policy individual companies have with Aetna.

This thread is from 2003. Does that help with your confusion?