My medical group must approve my surgery?!?!

[mommyluv6 2]

I called Aetna and they told me that my medical group has to approve my surgery and that they won't even see my paperwork for approval! I then called my medical group and they told me the same thing. I then called my surgeons office and they said the same thing. But know one can tell me for sure what hoops I have to jump through! They all made it sound that as long as I do what my surgeon requires and he thinks I need the surgery I will be fine. Has any one ever dealt with this?

[BeBeSpArKLeS 70]

Is your Aetna ***?

I have *** and had to get a referral from my PCP then approval from the surgeon with proof of medical necessity. Once they approved it went to my medical group to be approved then onto insurance.

[Peggy D 123]

What is this "medical group?" I have Aetna & my surgeon's office sent all of the information to Aetna for them to review. I had given my surgeon notes from my PCP & the rest he had from all of the tests & consults he had ordered.

Aetna's medical necessity criteria can be found here. It is very similar to others I've seen, including the H-M-O I used to work for doing medical review.

[mommyluv6 2]

I have Regal Medical Group. They all confirmed that Aetna *** and my plan works this way and Aetna will have nothing to do with my approval. However, my group uses the Aetna bulletin as a guide line but is not necessarily what their approval is based on. Ugh so confusing!

[sonya139 95]

What's the difference between your medical group and your surgeon's office? I guess I'm confused.

[Jerzygurl 372]

Does the medical group oversee and control the health plan?

[Cherryhair 88]

BCBS ***-PCP had to request referral then provider relations at hospital had to review file before first consult then dr/nut/psychologist and surgeon has to approve then it goes to insurance for approval meanwhile the stress of waiting is causing me to eat more- this process is my comorbidity