Steve's complaint:
January 22, 2014

Insurance Company: Aetna
Coverage Type: Health Insurance

• Claim Handling - Denial of Claim

Aetna Insurance denied my claim for an MRI to map and detect the remaining prostate tissue after prostate surgery. This procedure was requested because of a significant rise in PSA values after my initial procedure indicating that I had biochemical recurrence of prostate cancer.

Aetna said the procedure was not medically necessary since they didn't believe that my PSA levels were high enough even though my doctor said I was biochemically positive for recurrence of prostate cancer. I paid for the procedure out of my pocket. Long story short...my biopsy revealed that I had a recurrence of prostate cancer that required more treatment. I submitted an appeal with Aetna and they again denied my claim. This time ignoring my request to pay the claim even though i provided them with a copy of my biopsy. They wrote me a letter saying that since the claim was denied I was responsible for only paying my deductible and coinsurance and that the medical provider would not be paid even though I paid for it. So the initial denial was because my procedure was not medically necessary and the second response from Aetna was I don't have to pay and they didn't address my appeal.

I called the appeal claim team supervisor and she wouldn't discuss the claim with me but told me I had to file another appeal to escalate to the next level. I have filed a complaint with the AZ dept of insurance.

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