DENIED BY AETNA ON APPEAL

I can hardly type this, but I was denied again by aetna after an appeal showing 6 new, consecutive months of a physican supervised program done out of my surgeons office.

I dont know what I am doing wrong.  My doctor will do peer to peer, but i am so bummed.  I have applied for the surgery twice now (once in 07 and once in 10) been denied twice, and now denied on appeal.

I am so afraid that this assistance is not going to happen for me.  I am terrified.

Maria

 Oh I am SO sorry to hear this.  I'm really furious with the way this whole system works!  You have to work your ass off, pay the co-pays, attend a million meetings and appts NOT KNOWING if you'll be "approved" for surgery?!  It's nuts.  Your insurer should approve you if a doc says it's necessary.  Short of they you should be able to get a "conditional approval" based on completing your doc's requirements.  This really gets me steamed.

What are their reasons?

All I can do is hope for you and hope that your doc is very good at this.  Is there a dedicated insurance person at the office who handles everything?

Hearts and more hearts ...

What is their reason for denial?  They should have provided you with a reason of why you were denied such as lack of 2 year history of obesity, BMI did not meet requirements, etc...  What was their reason?

They will not read me the denial over the phone, or fax or email a copy, so I have to wait and get it in the mail...

My BMI is 62, so thats not the issues, my co-morbidities are high cholesterol, sleep apnea, lower extremity edema, depression, lower back pain, my six month program was consecutive, and was done in a physicians office, with 2 pages of notes for each visit, signed by the physician each time....

I am livid, but will keep fighting.

I so feel your pain.  I am going through the same thing.  I had the rug pulled out from me.  My surgeons office calls me and says I was approved, I do all the pre-op testing and they start me on a liquid diet.  I am on liquids for a week and then get a letter from my insurance saying they are denying my surgery.  Oh boy was i depressed.  My surgeons office does a peer to peer and an appeal and it was denied as well.  I just sent in a request for a Fair Hearing on Wed and am waiting myself to see what is going to happen next.  I have a BMI of 42, diabetic, sleep apnea, high cholesterol, high blood pressure, so I am well qualified as yourself.  I found a copy of a letter on this site and I used it.  Hoping that it works for me as i have seen it work for others.  My Health Advocate states there is a law stating that they cannot deny us, not sure how to make that work.  I wish you the best of luck and we will have to stick together to succeed.  I will not quit either.  

 
What was the reason for the denial?

They really had no valid reason.  Said they didnt receive some my labs and didnt see that i was on Statins.  My Dr sent over 106 pages and was very thorough.  The surgeon says they are just trying yank my chains it sounds like.  Pretty frustrating as I am ready to be on the losers bench.

When you get the denial letter in the mail, let me know what it says.  My daughter's as well as my friend's denial letter stated 'lack of proof of 2 years of being obese."  Could that be it?  It sounds like all the other requirements are met.  I'm pretty familiar with Aetna's requirements because my daughter and I were denied, then approved in appeal.  A friend of mine was denied and I helped her with her appeal, and she got approved.  My son's documentation is with Aetna as of last week and we are waiting on an approval for his surgery!!  I feel your pain because I have been there.  But don't give up!! 

Once you get the denial letter, let us know what it says and I can certainly forward you the appeal letters I used for all of our appeals.

Nan

Well, went back to the doctors today, so that I can get another months worth of phydician supervised diet on the books, just trying to do anything I can to continue to gain the paperwork neeed.  I am trying to keep my chin up - but its not easy.  As I do not have the letter, I cant tell what the denial is for, but I will wait for the mail and as soon as I begin in, do the next steps.

My company is self insured, so I am not sure how that is playing in - so I am trying to investigate that...

thanks for all the well wishes!

Maria

Id add to get a copy of the insurance criteria from the Aetna website.  If each criteria is met and they denied you may have legal recourse.  Hang in there I went through it 5 years ago but got my surgery and am still doing well.... its worth the fight :)