Aetna Appeal Letter

Hello everyone.. I was denied from Aetna on Sept 17 2012... after 6 longs months on the program to get approved. I was denied due to not having 2 years worth of weight history. My BMI is 63 and I'm 24!! that beyond needing this surgery!! Finally after 2 months of being depressed I've decided to see what can I do to get approved. I would love if someone can help on writing or brainstorming the perfect letter to get approved. If anyone has pointers or the best practice to writing this letter please message me..thanks

Don't feel too bad - Aetna denied my husband after he jumped through all the hoops because they said his high b/p wasn't a co-morbidity because it was "controlled" with medication.  The bariatric surgeone even did a peer-to-peer review with Aetna's medical director and it still got denied.  

Aetna is the biggest piece of crap out there right now in the insurance world.  Their merger with Coventry has been a DISASTER for policy holders.  I work for a major hospital and we are constantly battling with them over claims that get denied in error, claims they refuse to pay in error, etc.  

I desperately need help with an appeal letter.  I currently have a hernia and need surgery ASAP for it.  I went thru a 90 day program with the hospital but now Aetna is denying me for surgery.  The letter says it was because I did not have 2 years of weight history and I did not have either a 6 month diet plan or a 90 day program.  I did the 3 month program with the hospital but it was not technically 90 days the hospital is telling me that shouldn't matter and that Aetna is never that strict.   Problem is each week my hernia gets bigger and I need the Gastric surgery to help me lose weight so it does not come back, I just had surgery for a hernia last March.  When I called Aetna they told me that it was denied because of my weight history and not haveing a 90 day program like the letter says but the doctors office is telling me that they are being told that my plan does not cover a 90 day plan and that I need to do more than 90 days.  I am telling them that the letter does not state that and I have even sent them the letter and they say they understand but they cannot make Aetna approve the claim.  They feel like they are just trying to deny the claim for some reason.  Any help anyone could provide would be greatly appreciated, I feel like my only course now is to file an appeal but they told me an appeal could take 8-12 weeks and there is no way I can wait that long to have my hernia surgery. Does anyway also know of a way to get an expedited appeal?

Thans for any help

Unfortunately, Aetna is that strict (at least regarding the 3-month/90 day diet).  It really needs to be at least 90 days (I did mine for 100 just to make sure).  I am not sure what you mean by your plan not covering a 90-day program - mine didn't either, so I paid out of pocket for one - it was worth it to me.

If you don't have the 2-year weight history, there is not much that can be done right now, at least as far as appealing Aetna.  That is their requirement, and they are entitled to set their requirements.  This requirement is pretty common for most insurance companies, so it is not outrageous, egregious, or arbitrary.  How close are you to meeting the requirement?

As for the 90-day plan, keep going - don't stop.  If not more than a month has passed since you last saw a doctor for the diet/program, you should be able to keep going and have it count towards the 90 days.  One more visit ought to do it, and then you can resubmit.  At least as far as the 90-day program goes.  This won't help your weight history, see above.

It really sounds like you need to get your hernia repaired, and then worry about qualifying for WLS.  I'm not sure that Aetna will see the two as being related.

Good luck.

Thanks for the info.  The 90 days would have been up by the time my surgery was suppose to be in December, they are actually asking for a 3 yr weight history which is now moot because I had a weight taken this year which gives me 3 years of weight history now.  The issue now seems to be that they are saying that my plan does not cover me doing a 90 day program which makes no sense because that is not what they told me when I called before and during the process.  Aetna is telking me the only thing I can do is have the doctor do a peer to peer or do an appeal.

What do you mean by "that my plan does not cover me doing a 90 day program?"

I am not sure, I think the lady at the doctors office wasn't really trying to do her job.  She just called me back and said she talked to Aetna and they said it was denied because I did 88 days and not 90 and that now I have to send in an appeal letter.  She said they have never seen them be this strict before and that this has never happened.  So now I need an appeal letter example and need to know how to get Aetna to expedite it.

I am not sure you can get them to expedite an appeal.  It certainly wouldn't hurt to try it, but I'm not sure of the process.

Instead of appealing, can you do 3 more days of the program, and then resubmit your paperwork to Aetna?  That might be faster.  And, I have heard that Aetna is notorious for being strict about the 90-day program - so I am not sure where the doctor's office lady gets her info.  They want at least 90 days.  If you can see a doctor now, and have them write down your current weight, what you've been doing since the 88th day of the program, and document your vitals, maybe that will be enough to qualify for the 90 days.  The 90-day program does not have to be a specific "program" per se, there are just certain criteria that need to be met, and you need to be dedicated for at least 90 days.

Good luck!

They said they will not accept any new information, I did go in again this month on the 31st which would technically give me about 120 days but she said my only option is to do an appeal at this point.