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Angie,
I have Aetna insurance and also did the 3 month Multidisciplinary program. My daughter also has had surgery and so has a friend of mine, all of us having Aetna insurance. I'm sure you have looked at their clinical bulletin 0157 for the 'requirements' . If you meet those requirements, there should be no reason why you can not appeal and get this overturned.
In your denial letter, what is the reason they are giving you for denial? I was denied, my daughter was denied, and my friend was denied. I put together appeals on all three of them and eventually all three of us were approved.
Basically what it comes down to is they hgave requirements, and if you meet them, you will get approved. If you are denied, think of it as a bump in the road but don't give up!!
I will be glad to share the letters I wrote in our appeals. PM me if you'd like.
Again, read the denial letter and find out the reason they are denying. Then, provide that information to them so the decision can be overturned.
Nan
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
Highest 255 Surgery 248 Current 170
Goal: 150
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 ...
Highest 255 Surgery 248 Current 170
Goal: 150
Fight the *******s.
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
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
After my first denial (the lady at the surgeons office said that the medical reviewer practically denies everyone) my PCP and that reviewer did a peer to peer and he requested my entire file-18 pages of info. Still denied it which was why it went back to East Ohio Conference. I don't know if they are self funded..but when I spoke with the lady at EOC she told me that she felt I should try optifast again...or a supervised hospital program...it just felt like it was her "opinion".
So, how would I request another peer to peer? Have my PCP contact the lady I spoke to at the East Ohio Conference?
I greatly appreciate your help.
And advice! I feel alone doing this!
Angie
Do you have any appeals left?
Exhaust your appeals explaining that you have met every single insurance requirement and if they deny you then get a 3rd party person in there. State insurance, etc.
You can also opt to hire Walter... i forget his last name but I can get it for you. It will probably happen sooner with him, but cheaper with the state ins.
When does your fiscal year end? Could they be putting you off because benefits will change and perhaps WLS won't be covered?
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
After my first denial (the lady at the surgeons office said that the medical reviewer practically denies everyone) my PCP and that reviewer did a peer to peer and he requested my entire file-18 pages of info. Still denied it which was why it went back to East Ohio Conference. I don't know if they are self funded..but when I spoke with the lady at EOC she told me that she felt I should try optifast again...or a supervised hospital program...it just felt like it was her "opinion".
So, how would I request another peer to peer? Have my PCP contact the lady I spoke to at the East Ohio Conference?
I greatly appreciate your help.
And advice! I feel alone doing this!
Angie
Hockeymom87 · 0 replies · 631 views
