Gary..Am I wasteing my time??

I am on my 3rd denial for Aetna. My Dr just did a peer to peer & they did not over turn my denial. My denial is based on my BMI went under 40 in the past 5 years. I have co morbs, just not the ones they list as approving if your BMI goes under 40 (35 or higher).  My BMI right now is 44

There co morbs are  Coronary Heart Disease, Type 2 Diabetes, Signficant sleep apena, hypertension.

My co morbs are  GERD, heel spurs, edema, back/knee pain and arthritis.

Seeing this what they require in there clinical bullition, What are my chances to win a case like this & get approved or is it slim to none?

Sorry to bother you..it's just a lot of $$ to spend that I dont have right now  to hire a laywer.  Thank You for your time.

Hello Paul,     Thank you for taking the time to post.  I already had a sleep study, I was so positive is had Sleep apena, but it turned out I dont, I have to go back in a few weeks, for another sleep study & then a nap study the following day, to figure out why I'm so tired & wake up a lot during the night & snore so much & loud.  As for my DR, he was a jerk & I have found a new one that has done this whole process before.  Everything else medically is ok. So I will start going to my new Dr & build a better case. I'm soooo glad I pay hundreds of dollars a month to have this GREAT insurance & when I really need them they are good for nothing.

I have worked in a sleep lab and honey, if you are snoring and waking up at night, then chances are you have sleep apnea.  It sounds like the technician didn't do a good job on your sleep test.  The test you are going to have is to test for narcolepsy.  (the one where you have to take naps) Keep up the fight!! Julie

Well, it is going to depend on two things.  Whether you have a right to appeal again, and if so, are you allowed an appeal externally. If you can get an external independant review go for it.  They are MUCH more foregiving on these things.  If not, keep appealing.  If they tell you that you have no more appeals left, then have your surgeon resubmitt again, get denied, and keepappealing that.  Don't let up on them because that is what they're expecting. In either case, I think you're out of florida?   I have had great success with the Florida AHA.  So have others I know of.  When you file a complaint with them they actually investigate it unlike other states, and if they are being unfair, not following the rules or didn't advise you timely of something, AHA will come down on them.  You can find a link to them on the left side under appeal rights by state.

Sorry,  I meant AHCA and here is the link http://www.fdhc.state.fl.us/Contact/call_center.shtml They are very good to deal with.  Remind them that the NIH criteria is 35 plus a co morb and 40 with non.  You meet that.

Hey Julie,  see I told you not to give up! You have to fight and they will see that you are not giving up and adventually approve you!!! Hang in there girl and be strong! Oh and could everyone say a prayer for me today please ! My peer to peer review is today with Aetna and I don't feel so confident about it because they are denying people left and right!                                                                        See ya, Kat