Denial is more than a river

I just got the dreaded denial letter yesterday so I started working on my appeal today.  I do have a question.  I have Aetna and in their Clinical Policy Bulletin they state as a requirement that “Presence of severe obesity that has persisted for at least 5 years, defined as any of the following...”

 

 

My question is there was a short time in my adult life when I got down to simply overweight and not in this category.  Then the pendulum went back to the other side.  I am waiting for my chart to find out but I don’t know if 5 years ago to the day I was classified as such but I can show from my medical records of 7 & 10 years ago that I had this.  Do you have to stay over the 35 for the full 5 years or will I be able to show this has been a problem even longer?

I am curious to this answer too.  Since you listed 35 BMI as reference, I assume you have co-morbidities.  Do you mind giving those details?  Please let us know the outcome of your appeals.

I have sleep apnea and the nice thing about that is they paid for my CPAP so they can’t turn around and say no that is not good enough.  I also found out today if they want it to be 5 years over the 35 as of January 18, 2006 I can actually show that I have had a BMI for the full 5 years.

 

One more reason they denied is because I went to the doctor for 3 moths (once a month) they say that I only went for 60 days and not the 90 required.  The nice thing about that is my doctor’s office has one that Aetna approved that did the exact same thing I did.  And if I am correct under the ERISA guidelines they have to handle every claim the same way.  So his office is going to ask the other person if I can use his name. 

 

If he allows it I am going to save that card however and argue that I did everything the way I understood the rules to read and the insurance consultant at the surgery center interpreted it the same way.  Thus it would be easy to show that there are some ambiguities in then way it is written.   With that the courts have held in the past that in the case of ambiguities in the wording they favor the insured.  That is my story and I am sticking to it.