Appeals Review

I have been denied by Aetna for VSG. First because they stated I didn't meet the criteria of weightloss. However,  I appealed and proved that I do meed the medical criteria however,  they came back with a second denial because they say that I didn't meet psych clearance. Which was untrue. I faxed in the pysch clearance but now they want to do a Level II appeal committee tele - conference. I can choose to phone in and state my case to an unknown board I will be given 15 minutes to do this. Then I will be asked to leave the call where they will deliberate without me and send me a letter with their decision within 5 business days. They also state that I can have a lawyer present it I want to. WTF.  Does anybody have any experience with this? What should I expect?

 Self pay for surgery - $50,000.00
One hour for lawyer - $200.00

You decide

Here are a couple of links about insurance appeals that might be  helpful:

Insurance Appeals 1

Insurance Appeals 2

Also you might want to call the OAC and get their suggestion. You might also want to call your state insurance commissioner as well.

Thanks Maria fot the suggestion,
I will definitely look into this.

check out www.obesitylaw.com. They may be able to help you ans will have a phone number if you want to call instead.

good luck,
Holly

I wonder if there is a way your doctor can be present as well.  If not, call your insurance and ask them to set up a peer-to-peer conference with your physician.

Why would an insurance company suggest your lawyer be present.  

Do all the research you can, get your speech ready and be very concise about each reason you are qualified.  (maybe put them on flash cards)  Practice ahead of time and time yourself to keep it under 15 mins. 

And yes, I would consider calling the insurance commissioner.  And let Aetna know you are doing this!!  That sometimes makes a difference.

Great advice hazelnut. Thanks