My Aetna summary plan description clearly states that 60 visits per year are covered for physical therapy. Nowhere does it state that after 25 visits the PT would be subject to medical review. I underwent radial head surgery on New Year's eve and have undergone painful and progressively active-assisted physical therapy since mid Jan. I have not reached my maximum medical improvement nor my max of 60 days. Aetna's online claim tracker shows checks issued to my physical therapy office. However, last Friday I receive a letter that RETROACTIVELY denies payment for my physical therapy after March 8 based on a Clinical Bulletin that is not referenced in my summary plan description nor was ever mentioned when the member services told my PT office that I was covered for 60 visits prior to my even starting physical therapy. Aetna's plan misrepresents its coverage and to my detriment I relied on their written words and issuance of checks. It isn't a new tactic, on Oct 24, Aetna settled a federal lawsuit with doctors over the same issues. I am appealing as high as I can go, but I can't even reach a case manager cuz they hide behind their automated phnoe system.
According to a report on the lawsuit: The settlement requires changes and commitments in Aetna's business practices to eliminate "the worst of the improper practices involved in managed care." Among the changes, which will affect all doctors treating Aetna patients:
Eliminating downloading and improper bundling and computerized denial practices.
Establishing the standard of a "physician, exercising prudential clinical judgment" for "medically necessary services, and allowing cost to be considered only when an alternative service is at least as likely to produce equivalent results."
Creating a dispute-resolution procedure, using an independent external review of decisions regarding medical necessity.
Providing a facilitator to assist physicians in enforcing the agreement.
Creating a $100 million fund for physicians to recover some of their damages.
Establishing a foundation "dedicated to promoting high-quality health care."
The agreement also requires Aetna to pay lawyers representing the doctors $50 million in attorney's fees, including $6.5 million in expenses.
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