Question:
ANYONE TAKE LONGER THAN TWO APPEALS?

I HAVE THREATENED AND THREATENED. MY INSURANCE BOOKLET STATES THAT THEY EXCLUDE EXERCISE AND DIET PROGRAMS BUT DO COVER TREATMENT FOR MORBID OBESITY OR OTHER LIFE THREATENING CONDITIONS. I HAVE SOUGHT AN ATTOURNEY FOR MY 3RD APPEAL BUT I'M PRAYING I DON'T GO TO THAT. I HAVE DIABETES, HIGH TRIGLYCERIDES, GERD, DEPRESSION, STRESS URINARY INCONTINENCE, CHRONIC BACK PAIN AND BORDERLINE HYPERTENSION. THE WORST IS A HORRIBLE FAMILY MEDICAL HISTORY. I DON'T KNOW IF THEY ARE WANTING DEAD CANDIDATES OR WHAT? IT IS SO FRUSTRATING. HOW CAN MEDICAID AND TENNCARE COVER THIS WHEN I HAVE PAID FOR INSURANCE MY WHOLE LIFE AND CAN'T GET APPROVED? ANYONE TAKE MORE THAN TWO APPEALS? HELP!!!!!!!!!PLEASE!!!!!!!!!    — JOY C. (posted on August 8, 2002)

August 8, 2002
I totaly understand where you are coming from! I am in the process of trying to get approved my self. But i have already been denied on 2 seperate occasions..... Meaning i exhausted my appeal peocess 2x over the past 5 years legal halp may be what you need! All my thoughts and prayers
   — tamitoez

August 11, 2002
Hi there, I just wanted to let you know that I was denied insurance coverage SIX times!!! yes, a total of SIX before I was ever approved. It was exhausting, but I kept fighting and fighting! You do the same! Don't get discouraged, or lose sight of the end result. I, myself, am 15 months post-op, and have lost 252 lbs. I am now at my ideal weight! DO NOT give up!!! The very very best of luck, hon!!
   — Heather W.

August 26, 2003
Hi, Aetna will continue to fight you til you are blue in the face. Just to let you know: Here is what Aetna told me they require for me to determine medical necessity: 1. Presence of morbid obesity that has persisted for at least 5 years, defined as either: 1. Body Mass Index (BMI)* exceeding 40; or (I have been obese all of my life). 2. Patient has completed growth: I am 37 years old. 3. Patient has participated in a physician-supervised nutrition and exercise program: See above. The following items clarify what they will accept for #3: i. Participation in nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists. ii. Nutrition and exercise program must be 6 months or longer in duration. iii. Nutrition and exercise program must occur within two years prior to surgery. iv. Participation in physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who does not perform bariatric surgery. Now that I have fully met their requirements. They are saying the my attendance in the program was insufficient. My employer has agreed. So I am being advised to try again next year. I have decided that they could try the same thing next year and my fight would be that much more difficult. They, my employer and Aetna, have not given me any guidelines for what is acceptable, only that what I have done thus far is not acceptable. I am challenging this crap on the grounds that they never provided me with any guidelines of what was an acceptable physician supervised program. My program consist of an endocrinologist, surgeon, nutrional nurse educator and the use of an exercise physiologist post-operatively. Although, I don't think it would be a problem to see them before hand. I just have chosen not to. I joined a gym and utilize the instructions provided to me by my nurse educator/nutritionist. Good Luck...Keep fighting. Felicia Underdue
   — aflower1

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