Aetna Appeal Letter

I'm currently drafting up a letter for my husband's appeal to Aetna for surgery denial and am needing some help.

Let me tell the whole story so it's better to understand....
He began the process in Sept 2009, covered under my insurance which was BCBS.  He need 6 months of weight management but he had to stop because we lost our insurance coverage.  He was only able to do 4 months of weight management.  His current employer covers the surgery, so he's back at it again.  Last month was his first month back at it.  From what the insruance counselor said, Aetna would consider the previous 4 months because it was all within a 2 year gap.  (Aetna seems to have a mind of their own because they're denying that).  Another issue was for some reason either his weight management history wasn't submitted or didn't get faxed thru in error because they're saying that they only have weight history from Sept 2009.  I know that's incorrect because I'm a stickler with him seeing the doctor.

So I'm writing the appeal and am needing some assistance or input.

Thanks in advance!!!

Hi!

I can help you!  I have Aetna and I had surgery in 2009.  I was denied at first and sent in my own appeal and was approved to have surgery.  Then, in May 2010, my daughter was denied, I filed her appeal, and she was then approved.   In the fal of 2010, both of my sons were approved for surgery and had their surgery in December!  Do I have some experience with Aetna, what they are require, and how to file an appeal.

I will send you my appeal letters I used and also a list of what exactly we did to get approved.  They have two different routes you can take.  The 6 month physician supervised diet and the 3 month multidisciplinary program.   Three of us did the 3 mo MD program and my one son did the 6 month physician supervised diet.

It will help me, to help you, if you can tell me exactly what the denial letter said.  From what you say, he was denied for exactly what my daughter was denied for (lack of proof of obesity that consisted for 2 years).  And is sounds like they are not seeing that he completed the 6 month pcp supervised diet. Did you husband go each and every month for 6 months (seven visits total) over a period of 180 days??  That is what they are looking for.  Everything must be documented in the physician notes that he was there for weight loss, his weight, bmi, notes that he was following a  reduced calorie diet, exercising xxxx amount of days per week and documenting his behavior modification.

I will PM you!!  In the meantime, let me know exactly what his letter says and I will help you put together your appeal.

Nan

Hi,

I have also been denied by Aetna for bariatric surgery.  I wrote an appeal letter two weeks ago explaining my co-morbidities and providing a copy of the doctor's letters diagnosing me with diabetes, sleep apnea and stress incontinence.  Aetna is refusing to recognize the co-morbidities and stating that my BMI has not been at 40 for the past two years.  I am arguing that my BMI has been at 35 with the co-morbidities for the past two years.  So, my question is, what type of information should I provide to show that I suffer from the co-morbid conditions.  I provided them with my doctor's letter for the diabetes, along with the contemporaneous medical records from the doctor's showing that I was being treated for diabetes and that I was currently being prescribed metaformin.  Any insight you can provide will be appreciated.  I am really distraught because I thought for sure that the surgery would be approved this time.  Thanks, Gail

Can you help me with the appeal process with Aetna. I had lap band done in 2004. I have never been able to get fills in my band. I get very ill anytime they try. So I found a new bariatric surgeon and he tried t get Aetna to approve a revision, so he will take out my band and then do a sleeve. Aetna will not approve the Sleeve, but they will approve the band removal. My doctor told me I could do an appeal. There reason is because I have no documented co-morbidities. I have a BMI of 39 but no other health issues. I have done several diets, had a band and cannot lose weight. If possible would you please help me with the appeal process.

Hey there. I see that your surgeon is Dr nicholson as well. And I just got a call today from his office that Aetna denied my surgery. Any luck w/ how to go about writing this letter. And do you know if Dr nicholason will write an appeals too? thanks for your response.
have all is going well.
Paige

Hey Ms Nan. Dont know if you are on this site anymore. I sure do hope so. Im doing some research cause I received that call from my surgeons office that Aetna denied me for VGS. SO, I goodled appeal letters and came across this website and this forum. I saw where you helped someone w/ their letter to Aetna in an attempt to have my denied surgery, approved. I havent yet received my "offical" letter from Aetna yet, but when the surgeons ofice called me w/ the bad news, she told me it was due to my weight history. One time in 2010 my bmi was like 35.? and another time in 2010 it was 37.? And then they brought 2009 in the picture. Im like WTH. SO, I see that you have some experience on writing quite a few appeal letters, may I have your expertise on mine? I would sooo much appreciate it.
Hope all is well w/ you.
Thank you soo much!
Paige

Hi Paige,

I will be glad to help and send you copies of my appeal letters however it looks as if you have not meeting their criteria of being morbidly obese for at least two years as defined in their clinical bulletin 0157.  If you go to Aetna's website and in the search box, type in 0157 andit will bring up their clinical bulletin for the requirments to qualify for WLS.

The requirement for proving you have had at least a two  year history of being morbedly obese states that your BMI must be >40 for at least two years or >35 with 2 co-morbidies.  Since your BMI was 35 and 37 in those years you will need to have documented co-morbidies. 

Nan

Hey NAN~
i did go on there website last night and saw that it has to be @ leasat 2 years of bmi over 40. and then bmi 35 w/ hypertension. but from the letter that i will be receiving stats that my hypertension is being controlled. I dont know its frustrating. My surgeons coordinator told me that I should appeal. But then again, i dont know what records my PCP sent them. Thanks for your help. I will PM you my email address. And just hope for the best. I was reading all your post and they gave me alittle hope.  all i can do is appeal. And go from there. Thanks for your time.

Paige

Hey Nan,

My name is Erica I'm 20 and I got denied by Aetna to have my VSG. I stared researching appeal letters and I've been reading your replies and I was hoping you can help me with my appeal letter or send me a copy of yours so I can at least have some idea on what to say. I got through the pre surgical requirements part and my coordinator was so confident that I wouldn't get denied she had me starting my pre sergical testing and it came back I was denied. When I read the denial letter it simply said I was denied because bariatric surgery wasn't covered on my plan but they didn't include where it says that in the letter. My mom and I read the fine print on every paper Aetna ever sent us and it doesn't say that bariatric surgery isn't covered anywhere, so my surgeon said we should appeal it and it should be approved. This is where you come in to save the day!

PS I forgot, but since 2011, ive been morbitly(sp) obese, according to BMi calculations. It's now over 40+. Which has been that for over a year and 1/2. thanks again