Denied by Aetna, worth an attempt at an appeal?

Hi. 

I have Aetna and submitted my stuff for approval in July.  I was denied in early august.  The reasons they gave me were 1.) My BMI was not high enough in 2007 (it was 2-3 pounds too LIGHT.)  2.) I did not complete a supervised diet with my dr...or a NUT--but I did and the papers were all submitted. 

I have no comorbs.  I had a sleep study done and though I woke up 90 times they didnt think it was apnea. 

SInce submitting the forms and being denied, I switched to another PCP in the same office as my other one.  I did that because she had the DS with my surgeon and thought she may have better insight on how I could get approved.

I am planning to continue my monthly visits with her and document everything, of course...to count as my supervised diet.  I will re-apply in January because my 2008 and 2009 weights are totally high enough.  I cant believe I would be denied then....right?

Now, this new PCP wrote a letter to my sugeon requesting an appeal because my Fasting Blood Sugar was high and my cholesterol is consistantly high.  She listed those two things as being "co-morbs" and that my BMI should only have to be 35.  (However, Aetna says heart disease, DM2 , apnea, high blood pressure are their only comorbs.)  She also mentioned my family history, Depression.)  My original PCP did not mention any of this in her letter---or on her form when it was submitted the first time.

So, do you think I should just wait until January and try again (starting all of my deductibles over again) or should I try for an appeal.  I think I should also write a personal letter pleaing my case...anyone have a good one handy that I can base mine off of?

Thanks for listening to this long winded ramble.

Stacie

HEIGHT: 5' 3.75"
Six+ Month Diet
08/12/09 232 BMI 40.1
08/06/09 DENIED
07/16/09 231 BMI 40.0
06/18/09 229 BMI 39.6 (last wt. for 1st 6mo diet)
05/21/09 232 BMI 40.1
04/24/09 236 BMI 40.8
03/30/09 235 BMI 40.7
02/26/09 241 BMI 41.7
01/13/09 238 BMI 41.2 (1st visit)
Two Year History
03/28/08 237 BMI 41.0 (wt. for 2008)
12/17/07 229 BMI 39.6
08/16/07 225 BMI 38.9 (wt. for 2007)

I am in the EXACt same boat. I am 5'5 on a good day and currently 250. I started this journey with Blue Cross and switched to Aetna during my open enrollment time at work. They had a 3month nutrition requirement versus the BC/BS 6 month requirement. I called and spoke with their reps twice who assured me that the fact that I had a current BMI of 40 and was at least 100 lbs overweight was what I needed to meet their requirements. I went ahead and switched to Aetna and was able to cram all of my nutrition classes, surgery life skills classes, pulmonologist, sleep study, cardiologist, stress test, fitness veal, etc into the summer. The day before my surgery I recvd a call at 4 pm telling me Aetna had denied me. I was devastated. Hundreds of dollars spent by me (thousands by Aetna). I too have been told in the past that I was prediabetic ( when i was 20 lbs lighter) I developed gestational diabetes with both of my pregnancies. I have high bad cholesterol and low good cholesterol. My pulmonologist told me that I only slept a total of 4 hours during my sleep study and that I stopped breathing at least 4 times. He said he wasnt too concerned because my surgery date was so soon and that the weight loss would solve that problem. My denial also states that my BMI has not been 40 for at least 2 years. I had lost 30 lbs during my 2006 pregnancy and since then have gained teh 30 back plus another 20. Had I not lost that 30, Im sure my BMI would have been 40 for the past 2 years. I am so frustrated and considering an attorney based on the fact that their representatives misled me. Please keep me posted on your appeal. I will do the same. I wish you all the best of luck!
Tracy