Hi, Gang!

I was wondering if anyone has been able to appeal Aetna and win with missing info on the 2 year history. Aetna has denied my daughter because the weight from 2007 was below 40bmi and we are missing 2008 (2009 & 2010 were 40+). There are no co-morbidities though she is borderline with blood pressure and has mild sleep apnea. I just find it so hard to believe that she completed all of the requirements and they are going to make her wait 5 months. We have a horrible family history (my husband had his surgery today and I am scheduled for 8/16 plus her granmother and even great-great grandmother are/were obese). Given she is only 20, why would they want to wait until she has health problems before approving this?

We did the multidisciplinary 3 month program and I was told this would still be good in January (this is when she should be approved with no issue since we will then have 2 years history) but recently read that this is not true. I really feel like if they are going to make her wait until January she should continue with the doctor, dietician and psychologist every month if for no other reason than to make sure she is compliant (and run up the bill- deductible is paid so we might as well get some benefit).

ANY, and I mean ANY suggestions are appreciated!!!

I feel your pain.  I was denied by Aetna in October of 2009 due to not having the full 2 years of weight history.  My first weight was December 4, 2008 so I can't resubmit for approval until after  December 4 of 2010.  A FOURTEEN MONTH WAIT.  I only have 5 more months to go and it's been a long haul.  I will have to redo my 3 month diet because it has "expired"  - it has to be completed within 6 months of surgery.  I start diet #2 the 30th of this month.

It's been my own experience that there is no way around the rules.  That missing year you ran into was the same problem I had.  But I do wish your daughter the best of luck, as well as your husband and yourself.  That should be one heck of a support system!

I do want to mention that I decided not to waste energy on an appeal.  My own denial was 100%  justified - the requirement is 24 months of weight history and I didn't have it, period.  You may feel different.  Come December, though....I GOT 'EM!!

Kathy

Hi,

Myself, my daughter and a friend of mine were all three denied by Aetna and I appealled each time (helped my friend with hers) and all three had the denial reversed and got approved to have surgery.  All three of us did the 3 month MD program. 

Don't give up.  I will send you samples of the letters I wrote, my physician wrote for the appeal.  My daughter was denied for the exact same reason but once we appealed, it was overturned.

I would do two things....
1)  appeal and hope she gets her approval. 

2) CONTINUE seeing her physician and dietician until she gets her approval.  Don't stop going because you are right if for no other reason than to make sure she is compliant.  If they do not change their mind on the appeal and she does indeed have to wait until January then she's completed the 6 month physician supervised diet (along with the 3 month MD program) but you don't want to take the chance of her being denied for the 3 mo MD program being 'expired'.  

I will PM you the stuff I have if you want!  Let me know.

Nan 

 

I would love to see your sample letters! Our plan is exactly as you said- appeal and hope we can get the reversal and keep up with the doctor/dietician in the meantime. I am gathering all of the information we can find, minus of course the 2008 weight, and she has an appointment next Friday with our PCP to see if we can get his help as well.

I really appreciate the help. Thanks, Nan!

PS You look great!

Michele
 

Hello-this sounds similar to what I have dealt with-please post your advice-I would love to read it and it would help keep me positive during this waiting time!

Angie

I don't know if it was for Aetna, but someone posted somewhere they used pictures and a doctor's letter that although they didn't allow weighing at their annual visit, they were the same weight and the pictures substantiate that the patient remainded at the same weight during the period they weren't weighed.