RE: Writing my Appeal Letter.....Help.....

Please if anyone can assist me in writing my appeal letter I would greatly appreciate it...or show me or direct me were i may be able to find a copy of one...a good one...I cannot afford lawyers fees...and i am appealing the exclusion in my policy...Please help. me...thank you I have Aetna..I have finished all the required 3 month regimen pcp, nutrionist, and psych..but becaus of my exclusion they are denying me...

Hi Madelaine, Will Aetna pay for the surgery if it is medically necessary? If they won't, you may be spinning your wheels and setting yourself up for more heartache. Assuming you have a BMI of 40+, call and ask them if they would approve if medically necessary and with a diagnosis CPT code of 278.01 (morbid obesity). My best advice, however, is to speak with the insurance department at your surgeon's office. They should be able to assist with an appeal. Ask if the surgeon could write a letter of medical necessity to Aetna's medical director, especially if you have documented co-morbidities. Bear in mind that you will probably have to pay for a surgical consultation at least, though, because such a letter is very time consuming for surgeon and staff. Finally, have your benefits reverified tomorrow. Most insurance benefits change on the calendar year. HTH, Kristen

Unfortunately Aetna will not approve due to an exclusion that reads as follows: Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs,exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. This exclusion was added after the fact..I was 30 days shy of completing my 3 month mutlidisciplinary regimen (PCP, Nutritionist, Pscych)..My employer tried to add a rider to change the policy and Aetna would not allow this to be done...I am looking for an appeal letter that will help me address this as a life saving procedure and not to cure my issues on comorbidities....I have stated in my post that I cannot afford an attorney and I have come this far in my journey to give up so easily...and take No as an answer....Also my surgeon will not appeal this for me ...i have to do this on my own...thank you for your reply.... Madelaine

Whatever you end up doing -- send a copy to the state of Florida insurance commissioner. If they changed the terms of the policy without giving you adequate notice you may have the grounds to go after them. I am no expert in these matters but it just makes sense to me that someone should have told you to go ahead and put in for your surgery even though you were 30 days shy -- then you would have been denied ---- but then when you appealed the decision it (might have been?) would have been under the old terms. At least it would have been worth a shot. So now, what you need to do is show how you were in the process of complying with their requirements when they changed the rules on you. Red

I have called Aetna and one of their representative informed me that they have notes of me calling in March of 06 and asking if WLS was covered and what I needed to comply for approval....that much i KNow..and they have notes in July and August 06...but they will not release them notes to me...they state it is for training purposes and not public information...it is in their network...The only way they will release if I pressure with a lawyer I was told by a friend who went through the same thing....but like i stated i cannot afford a lawyer.... Madelaine

Have you asked your human resources department to help you or call the State Insurance Commissioners office and ask for their advice, that is what they are there for. But everytime you call anyone --write down the date, time, and name of the person you talk to and the gist of the conversation. Your human resources department should be able to help as they are the people that deal with the insurance folks on a daily basis -- plus they are the ones that make the recommendations on which plan to buy. Do you or your husband belong to a union? If you do you could call on your union for assistance. In some cases the union would hire a lawyer for you. Red

Depending on which WLS you want, the manufacturers of the Lap-Band may go to battle for you. I understand that they are fighting insurance companies to get more approval for their system since it is cheaper, less invasive, somewhat safer, etc. I would also contact Stacy Posner (attorney) who writes in the magazine about WLS issues with insurance coverage. She may have a contact in Florida who would help you cheaply or for free?

If you get no satifaction then as last resource I would contact you State Representives and complain to them. You will be surprise how they can get things changed around for you if you contact them. Once the insurance companies hear that the politicians are contacting them, alot of times things will change in your favor. What do you have to lose? Good Luck! hugh