Need help with Aetna POS--how do I get approved? What do I need to do?

KD0715
on 4/12/16 1:55 pm

I am trying to work through the Aetna system and so far, have been met with a lot of frustration.  I was told to check on my approval by my bariatric provider.  So, I called Aetna and was told that my policy did not cover bariatric surgery.  HOWEVER, I know several people who have my exact same policy in my company who have had the surgery.  No, they did not self-pay or go to Mexico.  There has to be something that I am not doing correctly.  I am appealing to you--what do I need to do?  How do you get approved?  Aetna is sort of vague on their website.  On one hand, they say that tell you the exact steps that you need to take in order to do the surgery.  I'm on board with that.  Trying to get all of my stuff together.  NO PROBLEM.  My bariatric provider (on my first visit) went on and on about what I need to do (mirrored exactly what Aetna said on their website).  BUT... also on their website it says that they don't cover bariatric surgery. Am I using the wrong words?  I told the Aetna rep, when I called, do you cover bariatric surgery?  She said, "No, we don't."  I asked about riders or buying coverage. 

How did you navigate the Aetna maze?  What do I have to do to get covered?  I have an appointment in 3 weeks with my surgeon.  Do I let the provider submit it and then be rejected?  What are the steps that I need to take.  And, no I can't discuss the surgery with those that had it.  They are in another state and I would not feel comfortable in broaching that subject.

THANK YOU!

hollykim
on 4/12/16 10:42 am - Nashville, TN
Revision on 03/18/15
On April 12, 2016 at 8:55 PM Pacific Time, KD0715 wrote:

I am trying to work through the Aetna system and so far, have been met with a lot of frustration.  I was told to check on my approval by my bariatric provider.  So, I called Aetna and was told that my policy did not cover bariatric surgery.  HOWEVER, I know several people who have my exact same policy in my company who have had the surgery.  No, they did not self-pay or go to Mexico.  There has to be something that I am not doing correctly.  I am appealing to you--what do I need to do?  How do you get approved?  Aetna is sort of vague on their website.  On one hand, they say that tell you the exact steps that you need to take in order to do the surgery.  I'm on board with that.  Trying to get all of my stuff together.  NO PROBLEM.  My bariatric provider (on my first visit) went on and on about what I need to do (mirrored exactly what Aetna said on their website).  BUT... also on their website it says that they don't cover bariatric surgery. Am I using the wrong words?  I told the Aetna rep, when I called, do you cover bariatric surgery?  She said, "No, we don't."  I asked about riders or buying coverage. 

How did you navigate the Aetna maze?  What do I have to do to get covered?  I have an appointment in 3 weeks with my surgeon.  Do I let the provider submit it and then be rejected?  What are the steps that I need to take.  And, no I can't discuss the surgery with those that had it.  They are in another state and I would not feel comfortable in broaching that subject.

THANK YOU!

Aetna covers WLS,IF,your employer bought the coverage for their employees. Maybe your co workers bought a different,more expensive plan that includes it? Or maybe they had secondary policies from their spouses? How do you KNOW they have the exact same policy that you have if you are not comfortable talking about it with. Them? 

aetna will tell the ppl whose policy does include the coverage what to do. They won't discuss. It with ppl whose policy excludes it. 

Youneed to request a a copy of YOUR plan from them as that will tell you if it does or does not cover. 

The plan information on line is pretty generic. It intended for general information then you have to  look at your particular policy to see if it. I included or excluded.

 


          

 

KD0715
on 4/14/16 9:08 am

I really can't get into the politics of it but suffice to say that I know for a fact others with the same policy and exact same insurance had the surgery paid for.  No, they did not have their spouses pay for it.  I have the most expensive, highest end policy our company offers so that cant be it. HOWEVER, if they did go out and buy their own, I'd be interested in knowing how that works.  Mostly, how do you navigate Aetna POS?  Anyone have any luck?

ImShellNurse
on 4/21/16 1:58 pm

I have Aetna. I called member services and asked if it was covered.  They got my member number etc.  Told me it was covered and then emailed me a detailed document that basically tells what you need to do to qualify.  The member services rep was very helpful, but I do know that you have to tell them your member ID number and they will tell you whether or not your company has purchased the obesity rider.

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