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CGMS & Aetna 2nd Level Appeal Questions...

Discussion in 'Insurance Issues' started by Marcy, Jun 10, 2008.

  1. Marcy

    Marcy Approved members

    Jun 10, 2008

    I just received my second denial from Aetna. I will go ahead with their internal 2nd level appeal.

    I just wondered if I should write a new letter, or resend the other two with this appeal (How many times can I say the same thing)?

    Also, I used Paige's Dad's letter to create my first appeal letter. Aetna did not respond to any of my requests... for specific studies they used to deny the claim as well as the names (and medical license numbers) of their board members who denied my claim. Should I fight with them now about giving me that info, or just submit my 2nd appeal? It is so frustrating that I follow all of their procedures and when I ask them for something, they don't even acknowledge the request.:mad:

    Thank you for your help

  2. SaltyAndSweet

    SaltyAndSweet Approved members

    Mar 4, 2008
    Hi Marcy.
    So sorry you are having to struggle with your insurance. I just recently went through the same thing. I was able to get mine approved, but I'm having troubles getting them to actually pay for it. *sigh*

    I don't have Aetna, and I am not sure if they work like my insurance (GreatWest), but I was assigned a Case Manager at GW for my appeal. This person should be the one who is collecting all of your information and passing it on to whom ever is reviewing your case. The Case Manager would be able to answer some of your questions about how their appeals process works.

    Also, check with either the HR department of your employer, or if your company has an Insurance Broker talk to them too. My company has an independent insurance broker who was an invaluable resource in figuring out what hoops I needed to and in which order. They also would know what your legal rights are.

    My guess is that you probably do not need to send in things that you already have. But if I were you, definitely see who is handling your case at the insurance company before you proceed and see what the policies and procedures are.

    I hope this helps! Let me know if you have any questions.
  3. jendean

    jendean Approved members

    Aug 28, 2007
    Aetna pre-approved the cgms and then when I made a claim.... denied.
    "WE thought you were talking about a blood glucose meter..."
    even after I told them that this was the SOLE reason I would be buying this insurance thru my work, (we already have bc/bs from my husbands work)
    and explained PRECICELY to 5 people exactly what the cgms was.
    (this was before minimed had hcpc billing codes for these). I told them EXPLICITLY what it was for, and when they told me "yes", (three people told me yes) I wrote their names down and enrolled in the policy.
    Then they denied the claim, after I agreed to fork over 400 bucks a month to thier company.

    "we thought you were talking about a blood glucose meter."

    Yeah right. :mad:

    I hope it goes well. Good luck with Aetna... If you visit thier website, I dont know if you have, but they have a process detailed on there about appeals..
    You have to do thier gymnastics to get one, but it may well be worth it. I accepted another job, so I never got a chance to appeal again with them.
  4. moco89

    moco89 Approved members

    Mar 1, 2008
    I have United Healthcare right now, but thanks to my dad's employer, we're switching to Aetna in January. I'm not excited about this! At least I can get the sensors for about six months, but then I will have to appeal. I know I will have quite a few useful cards to play, for justifying my "need" for the cgms. At least with a cgms, I don't have to worry about passing out in a college lecture, and then the class leaving me behind.........unconscious! (yes, that really did happen-they thought I was sleeping.......)

    So I don't know, just keep on trying. Once the internal appeals process is exhausted/completed, you get to send your documentation to an external review board. You pay at most $50, and an anonymous endocrinologist/medical team evaluates your case, and makes the decision about the cgms. Whatever decision they make is a legally binding decision to your insurance plan. If the review team determines the cgms is "medically necessary", the insurance company is legally obligated to pay for the cgms. The majority of the time, the external appeals are successful. There are very few reasons why a endocrinologist may not support the use of a cgms.
  5. Sherri A

    Sherri A New Member

    Mar 6, 2008
    My second level Aetna request was also just recently denied. I wrote a totally new appeal level with lots of detail on studies and guidlines that were not reflected in their clinical policy bulletin....but with no luck. I will try again with the recent change to the Aetna policy bulletin, but I have already bought our CGMS, so not sure what problems that will pose.

    Sherri A.

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