Question:
Anyone with help on how to deal with Aetna on an appeal?

I was denied b/c they said that there was enough proof of the 6 mths diet history. I had 7 mths, but I'm afraid the Dr notes weren't good enough. I don't think that she had enough documention on them about my progress. What else can I do to prove to Aetna that I have the proof? Get her to redo the Dr notes? or just send in another letter from the PCP and elaborate on my 7 mths of dieting under her?    — sdbass (posted on May 13, 2005)

May 13, 2005
If you read the CPB ((http://www.)aetna.com/cpb/data/CPBA0157.html) carefully, you MUST send in copies of the medical records, with the required information recorded in them contemporaneously (i.e., the information had to have been written in there at the time of the appointment) -- a doctor's summary letter is unacceptable. If your doctor didn't keep accurate records, shame on her -- but also (and I don't mean this harshly, but ...) some of the blame is on you too, because you would have known this if you had read the requirements carefully when you started the 6 month diet, exercise and nutritional consultation program. It's all right there. If you didn't know about this ahead of time when you started dieting, because you weren't trying to get approval then, I guess that's just the way it goes -- Aetna is being a complete jerk about these requirements and you may well have to start over while following the requirements TO THE LETTER. I HATE Aetna, by the way. I was fortunate in that I had just quit a 16 month long clinical trial on an obesity drug (which didn't work for me) and the monthly appointments I had had, which included medical notes as well as discussions on nutrition and exercise, happened to be good enough to qualify, even though it had NOT been my intention to use the clinical trial notes at the time. Nevertheless, since I wanted the DS, I had to fight with Aetna for 5 months to get their denial of the DS overturned (the approved me for the RNY that I didn't want on the first request).
   — [Deactivated Member]

May 14, 2005
Shannon, I had the same situation happen to me. I called my PCP back and told them what had happened and they in turn sent a copy of my records AND my PCP wrote Aetna a letter stating it would be in my best interest to have the surgery and it worked!
   — Carole M.