What should we do!!!

[JDUB0414 0]

In January, I was approved for the surgery but my husband wasnt because he only had two year weight history. Since then We found 2004, 2006, 2007, 2008, no 2005. Also since then Aetna changed their requirements. We apealed and got a letter yesterday denying him again!!! WTF!!! It says he is missing 2005, what difference does it make if they only require 2 years. It also says they require two years of weight history. When we resubmitted, we turned in a letter from him, a letter from our PCP with the four years on it and a letter from his knee doctor. I dont understand what's going on and what to do now. He is very upset about this and it's hard for me knowing i'm getting my surgery Wednesday and he isn't even approved yet. What should we do???

[Wheetsin 714]

Call and ask for an explanation of the denial, if they haven't already sent it. If they require two years' history and are denying you because you don't have history from 2005, then ask them to reconsider/resbmit, and/or to talk to a supervisor or what several companies call a "rapid resolution expert."

[JDUB0414 0]

so today I called Aetna. These people are unbelievable!!!! Of course you cant talk to the people who make the decisions, so I asked to speak to the nurse that submits the pre-cert and no one seems to know what i'm talking about. They just keep saying to resubmit again for a second level of appeal. I am so mad!!!

[Wheetsin 714]

I know a bit about how insurance companies work behind-the-scenes, and I definitely can relate to it seeming like there's a hell of a runaround in trying to get anything done.

Did you guys submit for your husband's surgery, or did the surgeon's office?

My insurance company didn't want to pay for the anesthesia bill from my surgery. Something about the anesthesiologist office claiming my insurance company required the billing to be split between the anesthesiologist and nurse anesthetist, and my insurance company saying they already paid the bill (the paid the anesthesiologist half). It took me about 6 months to get it resolved, that includes having support from the anesthesia office and a lady in my surgeon's program who was invaluable in helping/advocating.

Just keep fighting the fight, really. Call them every day if you have to. That's what I did. A co-worker is fighting to get some charges from her infant delivery covered, and she calls first thing every Monday morning.

Actually, come to think of it -- I even arranged conference calls with me, the rep from the billing office, and whomever we had on the phone from the insurance company. I finally did that to avoid any more he said/she said. Perhaps that's an option if your surgeon filed for the approval.

[JDUB0414 0]

My surgeons office resubmitted with a two page letter from my husband and another letter from our PCP.