Updates on Aetna Appeal Denial/Peer to Peer question

Hi All-

Well I got my letter and basically they just said that they upheld their initial decision to deny the surgery based on the lack of six month documentation.

I did get exactly what my doctors office sent.  I was not thrilled with the way it was "presented" but the six visits were very clearly noted and charted, with 2 pages of chart notes per visits.

I have contacted a "health advocate" that my work provides, and she helped me build a case to get a case manager assigned by Aetna to review my file.

I have asked my doctor to call for a peer to peer, but I dont know if they allow that after an appeal has been denied.  Does anyone know?

I do have another "member appeal" which I am working on right now, but I want to try peer to peer first.

Thanks for reading, please feel free to give any insight or ideas!

Maria

Tenacity usually pays off in the end.  When I had my wls 5 years ago they kept denying my claim.  But I kept at it.  A thorough appeal can be done with legal back up if needed.  I think sometimes the insurance company denies to ultimately decrease their numbers of surgeries approved.  Who knows... but if you did what they asked ...then you did keep it up!! 

And keep up with the new healthcare legislation as it comes out... you never know if something will pop up you can use :)

why did they deny you again? if you met their criteria after their initial denial?  what was the reason?

they are upholding the lack of six month documentation, even though I had 6 visits with a physician and two pages of notes per visits... very confusing.... the worst part is they will not tell me why they are not accepting the documentation

i am so sorry this is happening to you.  i went to this site:  www.obesitylaw.com to see what services they offered in case i need them.  i think they are worth a call.  i dont understand how insurance company can get away with what they are doing.  please keep me posted!