RE: My denial by Aetna and past 2 year weights--will this info help my appeal?Also,...

..or is Aetna going to go strictly by the numbers and say oh well, you weighed 195 on 1/24/07, your only weight recorded for 2007, so we don't care WHY you were that weight.

The whole reason for the denial was not having a BMI of over 35 for the 2008 and 2007.  Well as I said in my previous post, the only time I was weighed in 2007 was one 1/24/07, at my six-week  post-partum visit after a very difficult pregnancy.  I weighed 195, which was a 33.5  BMI.

However, I had been extremely ill during the pregnancy.  I called my OB's office today and found out that my weight when I went in for my FIRST appointment with the pregnancy, on 5/12/06, was 212.  I lost 17 pounds DURING the pregnancy, when most women gain 20 or more.  (There are also records of multiple trips to the hospital for IVs, being on medicine for nausea almost the entire pregnancy, etc).  My BMI at 212 pounds was 36.4.

Do you think this will affect my appeal in any way?  I mean, will they consider that I was thinner only BECAUSE of being ill for 5 straight months during my pregnancy?

Also, I spoke to my surgeon's office and the surgeon is going to have a 'peer-to-peer' consultation w/the doctor who denied me at Aetna.  Does anyone know what that entails? 

DON"T GIVE UP!!!!  I was also denied b/c like I told you previously b/c my surgeon's office turned in the paperwork too soon.  Then, they recommended the 'peer to peer' review.  But I did not want, nor did my PCP recommend doing it b/c we knew I had not completed the multidisciplinary program yet.  So, i finished the program, then appealed.

But, to answer your question, what the 'peer to peer' means is your Doctor (or surgeon) will talk on the phone with Aetna's Doctor who is making the decision on whether patients are approved or not.  They will speak on the phone and your surgeon will plead your case and a decision will be made. 

What about 2009....why can't you use weights from 2008 & 2009??  Was your BMI over 35 during those 2 years. 

My suggestion would be to make sure whoever is doing the peer to peer with Aetna's doctor knows the whole reason why your weight dropped due to the difficult pregnancy, etc......so that they can plead your case.

Don't give up.....it still may get overturned!   I know you must  be so disappointed, but maybe it's just a matter of postponing it...like I said, do you have weights from 2008 and 2009 where your BMI is over 35 ?

Good luck to you!!

 

Thanks Nan--that's what I've been thinking--if I wait until January 2010, then they will have to use my weights from 2008 and 2009, both over 40 BMI.

My concern is--if I appeal, and lose, can I still resubmit it as a 'new' claim after the first of the year, when my 'weight history' will no longer be an issue?

Thank you, you've been so supportive.  I'm trying to hang in there.

I"ve been following this whole thing.  I don't really have anything to say except I'm sorry.....just reading your posts is painful.  Of course I'm currently waiting for Aetna to make a decision, and I want to thank you for your unknown gift of preparing me for what could happen.  I really am sorry.....and I hope it all works out for your best interest.