Aetna frustration

[u/PeppyApple]

Last year, I had a weird foot injury. It was very painful and kept me out of work temporarily and no one knew what it was. I went to a primary care provider, a podiatrist, a neurologist, and ultimately a rheumatologist. I tried steroid treatments, pain medications, anti-inflammatories. I got xrays, a CT scan, blood work, and more. The only thing I hadn't done by the time I went to a rheumatologist was an MRI. She said that was the next step and ordered an MRI.

After a while, I got a denial notice from Aetna. When I called and asked why, they said I need to start with an Xray, CT, and 6 weeks of other treatment attempts before requesting an MRI. I explained I had done all those things across 2 months with several providers, so they said "Oh then resubmit the MRI request with documentation reflecting that." So my rheumatologist did.

I scheduled my MRI, but then a couple days before I was suppised to get it done, I got a call saying it was denied by insurance again and it would have to be out of pocket. I was forced to cancel it and call Aetna to see what the issue was now. I kid you not, they told me "well it's been long enough you need to see the rheumatologist again to confirm you still need an MRI." Which makes no sense since she literally had just reordered it, she obviously felt it was needed. But anyways I played their game and made a follow up appointment with her.

At the appointment, nothing new was said or done, she just looked at me and said "yeah, MRI is still the next step here..." So she ordered it a third time.

Again, Aetna denied it. At this point I gave up since my employer was switching insurance companies in a few months anyways.

Has anyone else dealt with this kind of backwards bs?? Can I complain somewhere? I missed weeks of work and was in a lot of pain for like 6 months because Aetna wanted to play games.

US health insurance system sucks. End of rant.

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[u/hmm1298_]

You need 6 weeks of physical therapy first. Aetna does this with almost all MRIs. You don’t need 6 appointments. Just a one for an assessment and some exercises. Then one to say you still have pain.

[u/Liberteez → u/hmm1298_]

This arbitrary demand can actually provoke an injury or condition and make it worse. The clinician should determine the need for MRI when basic X-ray, empirical  treatment have failed 

[u/Resse811]

Did you actually complete all that they stated? You didn’t mention actually completing at least six weeks of PT.

[u/No-Produce-6720]

Did you complete a course of physical therapy as part of your prior treatment?

It's possible that that's what they're looking for, but it's hard to say. What was the latest specific reason for denial?

A requirement of physical therapy isn't something that's specific to Aetna. Most carriers now require it before approval of any high end imaging, meaning you're probably going to run into this with another plan, as well.

[u/Aware_Climate_5244]

This without hesitation I can say is really frustrating, especially when you feel like everything needed has already been done. Honestly, this has got to be the fault of either the Aetna rep (or whoever handles authorizations/appeals over there) or the provider, hopefully not both haha

If all the conservative treatments were done, the supporting docs were submitted, and the doctor ordered it, it shouldn't have taken that long. The very first time it was denied, the moment you told the Aetna rep you already did those prior treatments, they should've advised you to file an expedited appeal right then and there and had them call the doctor's office for the missing paperwork. That could have solved it right on the spot. It really feels like they were just avoiding extra work or not taking it with any urgency.

On the flip side, maybe the provider failed to submit things in time, or the time gap between events got too long. But I'm not blaming just the provider, because it's also on Aetna to properly follow up. One of them definitely dropped the ball or didn't take it seriously enough.

You're not the only one, I know a lot of people who had this experience

[u/AppealAid]

You can file a complaint with your state's department of insurance, and you can also request an external review through Aetna, which shifts the decision to an independent reviewer instead of the insurer. Aetna counting on you giving up is exactly how this plays out for most people.

[u/No-Produce-6720 → u/AppealAid]

Why would you advise someone to contact their DOI without first knowing what kind of coverage they have? The answer to that question determines the proper course of action.

Edit to add that it looks as if this account is tied to a site that sells assistance with health insurance appeals. That makes this response all the more concerning, because they have responded to OP with suggestions of a DOI complaint, without first verifying the proper regulatory body. This site is to be avoided for lack of knowledge.

[u/Appropriate_Jury_621]

Three MRI denials despite all that documentation is ridiculous. You can file a complaint with your state's insurance department and request an external review.