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eljefej
on 2/5/13 2:15 am - alexandria, VA
Topic: RE: Aetna Appeal Letter

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.

noftessa0401
on 2/5/13 2:13 am - San Diego, CA
RNY on 12/27/12
Topic: RE: Can I be refuse

What does your insurance policy say?  Each insurance company issues many different types of policies, with each policy stating different requirements for getting WLS. 

Most insurance companies require a certain BMI, a certain amount of time of that BMI history (usually 2-5 years), and some require a diet/program to follow before they will authorize WLS.

Usually the BMI must be at least 40, but if you have co-morbidities (like high blood pressure, sleep apnea, etc.), then your BMI could go as low as 35.  However, if you don't meet all of the requirements your insurance policy dictates, then, yes, they can refuse to authorize your surgery.  Just having the co-morbidities does not make the surgery a medical necessity.

Good luck!

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

noftessa0401
on 2/5/13 2:10 am - San Diego, CA
RNY on 12/27/12
Topic: RE: Aetna Appeal Letter

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.

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

cajeal
on 2/4/13 10:07 am
Topic: Can I be refuse

If I meet 2 of the requirements like high blood pressure and sleep apnea can my insurance co refuse surgery , wouldn't it be consider a medical necessary then

eljefej
on 2/4/13 3:38 am - alexandria, VA
Topic: RE: Aetna Appeal Letter

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

MustangLady
on 2/2/13 7:56 am - MA
Topic: RE: Waiting for approval is so stressful!! UHC
I don't have UHC buT I know what you are going through. I have Tricare and my packet went for approval on 1/14/13. I'm still waiting and I hate waiting. UGH!

~ CJ BradleyLapband Surgery 7/2007 with many complications. 2012 Seeking Revision to RNY. 2013 Revision denied. Trying to work with band.

    

mzlaura
on 2/2/13 3:48 am - Litchfield, NH
RNY on 03/05/13
Topic: RE: How long does it take to hear back from United Healthcare?

Congrats Sara! I have UHC as well just waiting for my approval stuff was sent in Jan 24th and more Jan 28th well the rest of it.. i am calling Monday to get an update. mail

HW: 401  SW: 297  CW: 200.8
RNY gastric bypass surgery on March 5th, 2013

  

sarapilar
on 2/2/13 1:20 am
VSG on 02/21/13
Topic: RE: How long does it take to hear back from United Healthcare?

I got approved!  Wait was 7 business days!  Yipppee!

"The most difficult part of changing how you live and eat is believing that change is possible. It takes a fierce kind of love for yourself."Geneen Roth
    
noftessa0401
on 2/1/13 1:19 am - San Diego, CA
RNY on 12/27/12
Topic: RE: X-post Appeal

Apparently their denial is typical on first-time requests like these.  Here is a link to an attorney (advocacy group?) that did a 2nd level appeal to Cigna and the revision was approved.  This was a while ago, but I imagine that the principles are the same.

 

http://wlsappeals.com/bariatric-insurance-denial-revision-ap peal/

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

Collette65
on 1/31/13 12:29 pm - Fairview, TX
VSG on 03/11/13
Topic: RE: Waiting for approval is so stressful!! UHC
I have BCBS and so I'm not sure. Insurance is scary, your life in someone else's hands! It's a love hate.

Collette

        
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