Denied Again...HELP!

My BMI is currently 40.8 w/ HB. I also have Aetna and they have denied me Lap RNY for a second time. I have done everything that was required of me.....6 months diet w/PCP, Psych eval., Nut eval. This is very upsetting. I have only had HB for 8 months...that is why Aetna denied me (at least,that is what they said). Can anyone give me any pointers as to what I need to do next....besides appeal again? I have heard through the grapevine that "Gary" might can help me.

That sounds like horse crap to me....You only recently have had co-morbidities so that is why they denied you...Does not sound right at all....Did you get your letter with the reasons for denial listed int it?  If you look up your medical policy it should state criteria.  I think it only takes a over a 40 BMI for 5 years.  How long have you been over 40 BMI?  I think they take 35 with maybe TWO co-morbids.  There has to be more to this than that...they may have done the standard DENY and see if she goes away, but the second denial...they usually dont deny again if you do qualify.  Please check into this more.  I have never heard of an insurance company saying well you have not had HBP long enough...not read that in any of the medical policies which I have read.   Good Luck

I have been between 35-40 BMI for more than 2 years now.......and almost 1 year with HB. That is what is sums up to be. I haven't received the "denial" letter from the insurance company yet.  I was just denied on May 29th. I plan on calling Aetna on either Monday or Tuesday and asking to speak to the "review nurse". I want to talk to her about the denial. I lost my insurance from Dec 2005 - August 2078. But, during that time I went to a "weight loss" clinic in my area...out of pocket. My friend works there and I'm also going to call her and ask if she will get the weight loss doctor to sign a letter for me. I also had to go to the hospital (ER) in Feb 2007, they thought that I had broken my ankle....I'm going to call the hospital and get those records as well. I couldn't afford to see my PCP during the time that I didn't have insurance.

Native - Gary has a thread "Questions" which should be on this main page.  Try and post your question on that thread!  I have my fingers crossed for you.  April

Aetna is real specific about their length of diets too. We do the 3 month surgical prep program listed in their criteria for our patients and they will deny if it is not 90 days. I had a patient denied for it being 88 days! I wonder if they are that particular with the 6 month diet. Calculate how many days your diet was from beginning to end. I might have only been 159 days or something like that. You could have been denied for something that stupid. Since your BMI was above 40, it has nothing to do with your comorbid conditions, it is something else.  You need a letter from your doc before the diet and then again after it, stating your progress or lack of. The first letter can be your "medical clearance" stating your health conditions, etc.  Then you have your diet documentation.  Then it should be followed by a doc that says something like "Sally participated in a 6 month medically supervised diet (please see enclosed documentation). She has been compliant and lost 12 pounds (etc). At this point, all non-surgical options for weight management have been exhausted. I recommend proceeding with weight loss surgery." If i had to put money on it, your denial is one of the 2 above reasons. Go to Aetna's web site and read their  criteria very carefully. They explain it in there. Bonnie

I'm currently using Obesity Law for my appeal.  You might want to try them.  The website is www.obesitylaw.com.  Good Luck! Gina