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Aetna denying medical bill

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gaggz

Member
I live in California
In Jan 2018 my son was little over 4 years and he had difficulty with pronunciation of certain words. The ENT specialist referred to Torrance Memorial Hospital Speech Therapy department. The diagnosis code was put as "F80.89" in doctor's orders. In Feb 2018, the hospital contacted the Aetna PPO insurance, and they spoke to some "Agent Sally" at Aetna who said the therapy is covered and no pre-authorization was required. In a few month's time, I started seeing "denial" in claims section at Aetna website. I was very worried as the amount of about 6-7 sessions came upto about $7,000. And Aetna denied all. Reason for denial: Diagnosis listed is "non-correctable" and they do not cover "non-correctable" disorders. If you look and talk to my child now, he is perfectly ok and made recovery well over 9 months ago. I called Aetna and told them child is normal, and I can send them a latest assessment from ENT specialist, but they are not accepting my arguement.

Over period of about 1.5 years I have been appealing with Hospital that I cannot afford to pay that amount. My annual income is over 100K so I cannot be given any assistance, but with mortgage and family expenses in expensive CA state its really hard for me (and senseless too) to pay the 7000. Moreover, the hospital filed an appeal with Aetna and they just denied the appeal.

I cannot pay so much. We clearly told Hospital at start of therapy that if this was not covered we would not have gone ahead with it. As a corrective measure, we have asked physician office to change the diagnosis code and re-bill. We are in process of doing this action, but I am scared Aetna shall deny my claim again. I have checked ICD codes and neither new nor old code states whether the condition is correctable or non-correctable. So from where does Aetna take its inputs. It is important to note that they have denied many other people's claims and even got sued (in some cases they have lost their lawsuits as well).

So where do I go from here? Where can I find out how hospital recorded their conversation with "Agent Sally"? what if hospital deny to provide us with the internal records or Aetna denies such a call was ever made. How can I fight the deceptive Aetna out? Even my employer cannot help me here? Please advise, thanks a ton for reading!
 


adjusterjack

Senior Member
Sorry, but at this point, where you go from here is to a lawyer.

Nobody here will have any magic words that would compel Aetna to pay.
 

cbg

I'm a Northern Girl
Of all the national health companies in the US, Aetna is the one I would least like to have to do business with.

Have you done a formal appeal of the claim through Aetna?
 

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