Aetna HELP Please!!!

I ust recieved my DENIAL letter and it basically reads like a laundry list of things that will cause me to get denied no matter what. I was denied because My co-morbidities were not severe enough. I am however confused. does anyone know... does you BMI have to exceed 40 for 5 years or does it have to hit exceed 40 at the time of submission. Does the fact that you have attempted weight loss with medication and exercise programs and loss weight only to gain it back count against you? Is there some type of lawyer that handles cases for WLS specifically and where do I find one? HELP please!

I am new to the board and just going through all of this but according to the Aetna website. I copied part of it but it goes into great detail about it. http://www.aetna.com/cpb/data/CPBA0157.html Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures: Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB or Lap-Band) medically necessary when the selection criteria listed below are met. Selection criteria: Presence of severe obesity that has persisted for at least 5 years, defined as any of the following: Body mass index (BMI)* exceeding 40; or BMI* greater than 35 in conjunction with any of the following severe co-morbidities: -Coronary heart disease; or -Type 2 diabetes mellitus; or -Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea); or -Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);

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I am a bariatric/general surgeon in Augusta. Aetna is notorious for this kind of stuff. There is no consistency. On patient gets approved and another denied. They don't want you to have surgery, plain and simple. There is a lawyer in CA that will handle denials. He is on retainer for Inamed and handles denials for free when they are denied for the lap band. He will handle gastric bypass denials as well. I have talked to him before and he says a typical case runs from 500-800 dollars. Not a bad deal to avoid months of frustration. You are welcome to call me and I can get you his number. Michael W. Blaney, MD FACS 706-738-3359

Aetna denied me on my first go around too. They seems to deny a lot of people the first attempt. I think they like to see if you will appeal and how bad you really want the surgery. Have you met all of their requirments? If so then you need to send in an appeal letter. If not then you need to go back and do everything they require and make sure your doctors are documenting everything. Aetna likes a lot of documentation. If you would like a copy of my appeal letter then email me and I will sent it to you. Take care.