Aetna - Medical Grp. Denied

First submittal to Aetna and I was Denied.... "Not Medically Necessary" How can that be.... above 50BMI Most of my adult life (Im 40) Two blood pressaure meds Pre-diebetic Constant leg and feet pain  History of Heart attack- diebetes Any suggestions??? Samples of good appeal letters?? Thanks all :)

So sorry to hear about your denial.   When everything was submitted was there a letter of medical necessity from your PCP and/or your surgeon?   Also do you think you may suffer from sleep apnea?  If you do, go for a sleep study  through your pulmonologist. All these co-morbidities add up.  I don't get it sometimes??!!!  Hang in there and keep me updated on what's going on. Best of luck, Monica

Hi Monica....Still jumping up and down..?? So excited for you :) Based on what I've read here on the boards I kinda expected to be denied, but I gotta tell you there was this little bit of hope that they wouldn't... You know I don't know what exactly was submitted by my PCP. On my last visit to Doctor I took along a bound book of records from my previous Doctors visits for the last several years with certain things highlighted, weight, diets, Blood pressure readings.. I also included photos (as much as I hated too)  I knew it was big and bulky so I asked that they add their records for the past 6 months showing my 6 month diet including documentation from the dietician and to call me if they would like me to hand deliver to medical group myself with the referral. After a few days, they hadn't called so I called them and the girl who handles the referrals told me she had faxed it... I have this feelin that she did not include everything.... very disappointing :(       As soon as I get the letter from the medical group stating the reasons why I was denied and hopefully some information on the appeal process, I plan on showing up at my doctors office and demand that they show me exactly what was sent. I have already called and asked for a referral for a sleep study test. but I fear that insurance will not pay for that either... will have to just wait and see.... and deal with it as it happens..  If I have too I will start asking for referrals for things I should have taken care of years ago.....I am in almost constant pain in my legs and feet.. I know I have artritus and that is documented in the paperwork that should have already been sent but I will take it further if needed... Anyhow... thanks for letting me vent I do have a question for you... I started this process with my primary doctor and I was under the impression that the referral I was denied for was to see the surgeon and then we'd go from there with other referrals for the actual surgery.. I noticed you wrote if I had a letter from the surgeon... ??  Did I go about this wrong? should have I gone to see the surgeon without a referral ? Do you HMO also ? Thanks again...  

Hi Kellie, I have Aetna Open Access PPO. I wonder if this is why we've had such different experiences with the same insurance company.  I actually started this entire process on my own without a Dr. I went to see the surgeon (no referral needed) and after I made my decision told my PCP. After that I took all the criteria I needed and started the process with my PCP.  This is what was submitted to insurance:   1. PCP notes on 6 month diet and comorbidities like arthritis and back pain.  2. PCP  medical necessity letter.  3. Nut. Eval.  4. Psych eval.  5. Surgeon letter of med. necessity including all my prior diets and weight history 6. Pulmonologist reports regarding sleep apnea.  I actually didn't see any of this. My surgeon's office took care of everything. I was so nervous about the entire insurance process. As you know, it's very stressful. Hope this helps you a little.  Hang in there and definitely appeal. Don't give up whatever you do. I'm glad you're staying on top of the insurance company.  If you need anything else just PM me. Lots of hugs, Monica

 

 

Man I wish i could be of help, but that is insane. I really didn't think Aetna had it in them to deny everyone on the first go around. I'd love to hear some success stories from people who got approved on the first try. I know people who have gotten approved just never the first go at it for some reason. I also got denied by them. I got tested for sleep apnea to go along with my denial overturn. I've been waiting 3 weeks now to hear back, and it is driving me up the wall. Are you on insulin? It is hard to read Aetna because on the website it says they want 2 co-morbidities, but then I got a letter saying they only want 1... They have to be High Blood Pressure, High Cholesterol, Coronary heart Disease, Type II diabetic, or sleep apnea. As for sample appeal letters, there are some on OH, and there are also some very kind women (and probably men) who are always willing to help people write them. They work with insurance so they know the deal. They typically check the boards every now and then so most likely you will hear from one of them. If not contact me and I will see if i can go back and find the names of others. I hope everything goes well. Keep us updated, and if you have any questions feel free to contact me and I'll do my best to help!

Alisa....  Thanks so much for your reply :) sorry to hear that you are in the Aetna battlefield also.. But sounds like you are almost there .... My fingers are crossed for a quick approval with a soon surgery date... Anyhow, yeah I'm jumping through their hoops.. If they think Im going to give up, ha... they are soooo very wrong. I am more determined now then ever....  No, Im not on insulin yet . I have only been labeled a PRE- Diabetic... haha... heck is that a good or bad thing..?? gheezzz.. My BMI is currently 54    (should be enough) Im on 2 blood pressure meds to control it. I have artritus in both my ankles and probably my knees... I don't know if I have sleep apnea but I have requested a sleep study test ... I'm falling deeper into a depression as this insurance process goes on...  Thanks again for your post.. and you are in prayers :)  Keep me posted on your progress...  Kellie

It wasn't Aetna's fault... Check out my last entry on my profile for more info..... Kellie :(

A doctor in my doctos office stated at our support group meeting that when she contacted one insurance company they told her point blank...we deny a certain percentage of claims for no reason whatsoever....just economics that some people wont appeal so we save money!!!!!!!!! I am sure that this is very very very true.  Jus look at what co-morbids you have!!! 

Somebody has the specific reason you you were denied beyond "medical necessity" Usually the letters read "We deem this surgery as not medically necessary. Medical necessity is determined by a BMI above 40.......etc, etc, etc, .........Medical necessity was not established as evidenced by...........(insert reason here---no 6 month diet, no co morbid conditions, etc)....... Sometimes the patient does not get that letter, the docs office does. You need to find out specifics in order to appeal successfully. You need to counterpoint each reason they denied you, not just resubmit a letter. Aetna makes us submit: letter from surgeon 6 month diet or 3 month surgical prep program letter from PCP nut eval pre and post diet psych eval 2 years weights letter from surgeon at completion of diet that says "Jane has exhausted all non-surgical options and I recommend proceeding with WLS" If your BMI is above 40 and has been, the above is all you need. Usually, it's something like the post diet nut letter that's missing. Either Aetna or your docs office can tell you the specifics. Bonnie

I was recently approved by Aetna and I had to have all that Bonnie said but 5 years weight history instead of 2.