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Thank you all for tolerating my tantrum. To explain my situation: I had to switch to an ACA HMO at the start of the year. I found a wonderful GP who was a great addition to my care team, as she was familiar with most of my oncology team. However, the rectal surgeon (who is in network), used the referral from last year so Aetna denied claim because there was no pre-authorization. Then they said I had needed to request continuity care for ALL medical care associated with the cancer so they denied all oncology follow-ups. Now they said they will not cover my colonoscopy because I had one last year (when the cancer was diagnosed) so I am not eligible for another for five years. @dlydailyhope
Replies to "Thank you all for tolerating my tantrum. To explain my situation: I had to switch to..."
It is standard medical practice to have a one year follow-up colonoscopy after diagnosis of colon cancer and treatment. Moreover, after the one year follow-up colonoscopy, it is usually recommended to have the next colonoscopy in three years--not five. It seems that Aetna is relying on the paperwork trail to deny coverage. This is not something a colon cancer survivor should have to be dealing with. Hopefully, this site can provide you with resources to address the probable illegality of this situation.
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@hopenjoy2024
Did your surgeon’s office not get preauthorization for your surgery and post surgery care? That is what they should do. Members/patients should not have to push this process when the provider needs to provide clinical information to Aetna for preauthorization approval. They should not have done the surgery until everything was buttoned up. I would ask that practice manager for help getting post surgery appeal approval of all medical claims for surgery and post surgery oncology. You may need an attorney to help you and you can check your state for help with your insurance claims. You should not be penalized during a scary time when you were relying on your providers for care.
I am fighting the same problem where Aetna is denying coverage of surgery and needs the surgeon to do a provider appeal. I met with him 6 weeks ago and my surgery is Monday. Why the surgeon’s preauthorization team dropped the ball, I don’t know. Very frustrating.