Dustie-- Aetna Appeal Help Needed

[Guest guest]

Hi Dustie... You have been so much help and I have more questions.

Aetna turned down Dr Hobar's appeal to pay for a DOC Band as in-

network. Tammy (at Children's Craniofacial) believed that CT had the

only FDA approved band for scaphy, but Aetna did some research and

there is another in-network provider who was approved so they turned

us down on those grounds... Turns out that it would have been a moot

point anyway, however, because CT put us in a side opening band due

to Blythe's asymmetry. Her case is a little complicated (scaphy with

asymmetry), so I am VERY glad we are with CT. I'm not sure that

anyone else really has the experience (or established protocols) to

deal with this. Probably, someone else would have put us in a

bivalved STARlight band which could have made the situation worse.

SOOO, I spoke with Dallas' CT office and she said that because Dr

Hobar's office sent us specifically for a DOC we could continue to

appeal and eventually Aetna might pay the in-network benefit. I

mentioned your name since our experience was so similar

(Hobar/scaphy/Aetna) and she said she was thinking of you as well but

couldn't bring up your name for obvious reasons.

Do you have any advice on how to proceed with Aetna? How did you win

your appeal?

I would love to know what you think I should do... We've been in the

band for a week and I think CT is doing a great job. There is a

chance she'll have to have a second band for the scaphy if this one

doesn't give us enough width.

Thanks in advance,

[Guest guest]

, Just a quick post. I read this and will get post my

big long post tomorrow a.m. bright and early. I will help you get

this paid for as in-network! Just you wait! I will send you the

documentation as far as education/experience which is the key!

Dustie

> Hi Dustie... You have been so much help and I have more questions.

>

> Aetna turned down Dr Hobar's appeal to pay for a DOC Band as in-

> network. Tammy (at Children's Craniofacial) believed that CT had

the

> only FDA approved band for scaphy, but Aetna did some research and

> there is another in-network provider who was approved so they

turned

> us down on those grounds... Turns out that it would have been a

moot

> point anyway, however, because CT put us in a side opening band

due

> to Blythe's asymmetry. Her case is a little complicated (scaphy

with

> asymmetry), so I am VERY glad we are with CT. I'm not sure that

> anyone else really has the experience (or established protocols)

to

> deal with this. Probably, someone else would have put us in a

> bivalved STARlight band which could have made the situation worse.

>

> SOOO, I spoke with Dallas' CT office and she said that because Dr

> Hobar's office sent us specifically for a DOC we could continue to

> appeal and eventually Aetna might pay the in-network benefit. I

> mentioned your name since our experience was so similar

> (Hobar/scaphy/Aetna) and she said she was thinking of you as well

but

> couldn't bring up your name for obvious reasons.

>

> Do you have any advice on how to proceed with Aetna? How did you

win

> your appeal?

>

> I would love to know what you think I should do... We've been in

the

> band for a week and I think CT is doing a great job. There is a

> chance she'll have to have a second band for the scaphy if this

one

> doesn't give us enough width.

>

> Thanks in advance,

[Guest guest]

, Good Morning.

First, where/who is Aetna saying can treat Scaphy in the area? I

would call Dr. Hobar's office and explain to their referral person

what is going on. Ask them for documention on that product Aetna is

referring you to, if any is available. Then, I would call or go by

the location, ask for documentation on the product they use, how

many times they have used it in the last year. Ask for their

education stats as well. Make sure you get specific with these

questions. If you ask a general question, trust me, you will get a

general answer. Remember that you are wanting the PERSON that will

be treating your babys' experience/education level in treating

Scaphy! Then, if you don't already have it, call Kathy at CTI or go

by to get the same information on the DOCBand and the Clinician

treating her. I KNOW that CTI's experience and education will be

more than where ever Aetna has a contract with.

Once you have all of this info call Aetna directly, ask to speak to

a precert dr or nurse. The customer service person that will answer

the phone only has a book to go by. Explain to them what is going

on. Ask how you go about filing a grievance because the referring

dr has written a rx for something and because it is out of network

it has been refused for payment.

Has Aetna actually denied you in writing as of yet? Whether they

have or not, it really doesn't matter because all of this material

will need to be sent in for a appeal anyways.

I never had to appeal a denial. I received a verbal approval and

then a nurse called me back with an approval number. Off the top of

my head, I can think of 3 Aetna members that rec'd in-network

benefits using the DOCBand in Dallas, simply because the

experience/education level was damn near ZERO in our area.

I hope this helps, let me know how it goes.

Dustie

> Hi Dustie... You have been so much help and I have more questions.

>

> Aetna turned down Dr Hobar's appeal to pay for a DOC Band as in-

> network. Tammy (at Children's Craniofacial) believed that CT had

the

> only FDA approved band for scaphy, but Aetna did some research and

> there is another in-network provider who was approved so they

turned

> us down on those grounds... Turns out that it would have been a

moot

> point anyway, however, because CT put us in a side opening band

due

> to Blythe's asymmetry. Her case is a little complicated (scaphy

with

> asymmetry), so I am VERY glad we are with CT. I'm not sure that

> anyone else really has the experience (or established protocols)

to

> deal with this. Probably, someone else would have put us in a

> bivalved STARlight band which could have made the situation worse.

>

> SOOO, I spoke with Dallas' CT office and she said that because Dr

> Hobar's office sent us specifically for a DOC we could continue to

> appeal and eventually Aetna might pay the in-network benefit. I

> mentioned your name since our experience was so similar

> (Hobar/scaphy/Aetna) and she said she was thinking of you as well

but

> couldn't bring up your name for obvious reasons.

>

> Do you have any advice on how to proceed with Aetna? How did you

win

> your appeal?

>

> I would love to know what you think I should do... We've been in

the

> band for a week and I think CT is doing a great job. There is a

> chance she'll have to have a second band for the scaphy if this

one

> doesn't give us enough width.

>

> Thanks in advance,

[Guest guest]

Thanks! My 2 yr old wants to push the buttons on my keyboard so I'll

write more later, just wanted to say a quick thanks.

I think it was O & P Designs (I need to get out our denial letter)

who does a STARbands that told Aetna they were FDA approved for

Scaphy... but since she is currently in a side opening band, I am not

sure it matters. After this band corrects the asymmetry, we may still

have to do the bivalved band, depending on the ratios upon competion.

This denial was a peer review appeal between Aetna's medical director

and Dr Hobar's office.

I will be down there on Monday for our appointment and will swing by

to get some info from the other provider. I'll also call Tammy today.

Tulsa

> > Hi Dustie... You have been so much help and I have more

questions.

> >

> > Aetna turned down Dr Hobar's appeal to pay for a DOC Band as in-

> > network. Tammy (at Children's Craniofacial) believed that CT had

> the

> > only FDA approved band for scaphy, but Aetna did some research

and

> > there is another in-network provider who was approved so they

> turned

> > us down on those grounds... Turns out that it would have been a

> moot

> > point anyway, however, because CT put us in a side opening band

> due

> > to Blythe's asymmetry. Her case is a little complicated (scaphy

> with

> > asymmetry), so I am VERY glad we are with CT. I'm not sure that

> > anyone else really has the experience (or established protocols)

> to

> > deal with this. Probably, someone else would have put us in a

> > bivalved STARlight band which could have made the situation worse.

> >

> > SOOO, I spoke with Dallas' CT office and she said that because Dr

> > Hobar's office sent us specifically for a DOC we could continue

to

> > appeal and eventually Aetna might pay the in-network benefit. I

> > mentioned your name since our experience was so similar

> > (Hobar/scaphy/Aetna) and she said she was thinking of you as well

> but

> > couldn't bring up your name for obvious reasons.

> >

> > Do you have any advice on how to proceed with Aetna? How did you

> win

> > your appeal?

> >

> > I would love to know what you think I should do... We've been in

> the

> > band for a week and I think CT is doing a great job. There is a

> > chance she'll have to have a second band for the scaphy if this

> one

> > doesn't give us enough width.

> >

> > Thanks in advance,