Question:
Help! Appeal denied.

I've read numerous questions and answers about Aetna approving WLS but my appeal has just been denied. I don't know what more I can send them. My appeal was 27 pages. I only had a 2 year history of weights but I listed 15 years of diets (no recent dr. supervised diets). Anyone have any suggestions?    — cp2639 (posted on October 26, 2002)

October 25, 2002
Christy, I would find out why they denied you. They must have a reason for denial. Once you find out why then I would make an appointment with my PCP and have him help you compose an appeal letter I have one you are welcome to use as a guideline if you would like. Just email me and I will be glad to share it with you. I was denied first go around with Cigna but got approved the second time with my appeal letter and my other doctors writing a letter on my behalf too. I was denied because of I had to have a medically supervised diet within the past 12 months which I had proof I did. I hope this will help.
   — Nicole H.

October 25, 2002
I just tried to go to the Aetna web page for you to get you the policy for Aetna and WLS, but they have taken it off the page. They must be working on changing it right now. You have a right to know that policy. I would first ask for them to send you a copy of thier policy, then write the letter so that you know you have meet all of their written guidelines. Quote the policy when you write the letter so that they know you have all the information. Good Luck to you.
   — Vicki L.

October 26, 2002
My daughter had LAP-RNY 11/19/01 and was covered by Aetna HMO. It was like she was literally approved overnite. And she was what we call a light weight.. 218 lbs. She has lost about 90 since then. It took me a few go-rounds with GHI to be approved, but call them and speak to the case manager. Perhaps the letter you sent in or the surgeon's letter didn't specify the medical necessity of the situation. Had the surgery on 10/8 and am now 18 days out. Good Luck to you.
   — Steve B.

October 26, 2002
Aetna has removed the Coverage Policy Bulletin #157 (Obesity Surgery) as of 9/20 - the web site says that the policy is undergoing revisions... I'm going to call my Aetna contact # on Monday. My WLS was covered, but my wife is going to get WLS in 2003 and I want to make sure that she will be covered as well...JR (open RNY 07/17 -96 lbs)
   — John Rushton

October 26, 2002
I have aetna HMO. They require 2 years medical history and a history of supervised weight loss attempts by a physician. I knew this going in so I mad sure I had the amount of time required. I also included a report of my life weight loss and weight gain. I was approved in 3 hours after submission by fax. I didnt have the complete 2 years medical history, I only had a year and a half. I also only had a few months of supervised weight loss. So they are somewhat flexible. I hope this helps. Michael
   — stroman69