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?

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.

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.

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!

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

Does the medical group oversee and control the health plan?

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