We have received several emails and calls regarding this same issue and that the member has had to appeal the denials from Aetna before having the procedure finally approved.
My understanding is that members should first contact their ordering hospital/physician and request that pre-approvals be sent to Aetna way in advance of the date of the procedure.
Secondly, if Aetna denies the test or procedure, they should contact Aetna to appeal the denial or have their physician/hospital contact Aetna regarding the denial and possibly resubmit the pre-approval, sometimes the coding they are using is the issue.
Third, the member should also contact the State of Illinois Department of Central Management Services and request the Medicare Unit. They need to file a complaint with CMS as well and ask that they work with Aetna to have the procedure/test approved.
I know this is a lot of steps, but the more retirees that start being proactive in their care and the more complaints both Aetna and CMS receive, will hopefully stop these denials in the future.
I do not have numbers for Aetna, but the member should have contact information on their insurance card. Here is the number for CMS: 1-800-442-1300.
Susan Goetz Illinois Retired Teachers Association Administrative Assistant 1-800-728-4782 firstname.lastname@example.org