I would like to ask for help. DS revision - Appeal Letter Assistance

travis1985
on 11/4/11 3:09 am - TX
Hello,

I come with hat somewhat in hand to ask this board for some assistance.  I have not been active in many months, and I am not sure if anyone would remember me.  So I am a bit embarrassed to express a need at this time (and I am a guy).   But, here is some quick background:

Oct 19, 2010
- Planned DS surgery, but due to complications, only had the Sleeve Performed.  This original DS was approved by AETNA as I have a very very high BMI (50 + easy)

- So began my life with a Sleeve, and the goal to lose 100-150 lbs, and get the 2nd stage of my DS

(Editorial Comment here - ITS HARD TO LOOSE WEIGHT WITH THE SLEEVE, I just want folks to know don't knowingly get a sleeve if you are BMI 50+.  The hunger does come back, and you have no malabsorption.   (note - the DS board has always said this, and i believed them, i just now have lived it)

- I have lost around 100 lbs., which is good, but i have a lot more to lose.

So here we are, and my question and request for help.

- Went to AENTA for pre-op approval and was denied due to the fact that Aetna requires a two year period prior to a revision
- Well, I am not a revision, I need my original procedure completed.  But the facts are I have to appeal, and I want to get this letter right.

QUESTION - I lost my email folder with all the good letter references from Diana Cox and other vets, so does anyone have a link to some verbiage that could help me in my appeal?

I know I am not the 1st to face this, and I would appreciate the help to get me where I need to go.....so i can pay it forward (and be around for my 3 boys).

Sincerely, thank you

T
Chad M.
on 11/4/11 3:17 am, edited 11/4/11 3:18 am - Indianapolis, IN
Diana and Larra have both helped plenty of people in this kind of situation and I'm sure one or both will be willing to step in. If nothing else, Diana's instructions for getting this process going are on dsfacts.com.

Personally, the first thing I would find out would be if there is anyone with Aetna who had a two-stage procedure done without any hassle. If you need to fight for a revision approval, by all means do so, but if there is some bureaucrat at Aetna that you can convince to punch your ticket, that's worth exploring.

And I remember you, I'm sure others do! Welcome back.
travis1985
on 11/4/11 3:54 am - TX
On November 4, 2011 at 10:17 AM Pacific Time, Chad M. wrote:
Diana and Larra have both helped plenty of people in this kind of situation and I'm sure one or both will be willing to step in. If nothing else, Diana's instructions for getting this process going are on dsfacts.com.

Personally, the first thing I would find out would be if there is anyone with Aetna who had a two-stage procedure done without any hassle. If you need to fight for a revision approval, by all means do so, but if there is some bureaucrat at Aetna that you can convince to punch your ticket, that's worth exploring.

And I remember you, I'm sure others do! Welcome back.


Chad, good thoughts, If anyone has ideas I welcome them.


And Chad, YOU ARE LOOKING SHARP!!!!!!! 
Chad M.
on 11/4/11 4:51 am - Indianapolis, IN
Thanks buddy! Good luck to you and keep us posted!
HeatherLynn
on 11/4/11 3:46 am - TX
I'm new, so I don't remember you. However, I wanted to wish you luck on your appeal. Keep us posted. 
travis1985
on 11/4/11 6:04 am - TX
 Thank you very much.....I apprecaite that Heather.
(deactivated member)
on 11/4/11 3:50 am - San Jose, CA
How was the request for pre-authorization submitted?  If it was submitted as a revision, then it was likely properly denied - YOU NEED TO GET A COPY OF WHAT THE SURGEON SUBMITTED TO FIND OUT IF IT WAS CODED PROPERLY.  The surgeon should also have DETAILED that he is now going back to complete a surgery that was PRE-APPROVED but which was not possible to complete at the time due to surgical complications, and that you are now ready to have the surgery completed.

You should file this information with an appeal of the denial, and make sure you get it filed prior to the time limit for appeal.  Find out if you can get your surgeon to do a peer-to-peer review as well.
travis1985
on 11/4/11 6:18 am - TX
Hi Diana, its nice to meet you.  I have not had the opportunity to message directly with you.  Thanks for your help.  That is very good advice.  I will get on that, I have been in contact with his insurance person. You train of thought, is as usual, right on.  The Peer to Peer is a good idea as well. 

I guess I am looking for some links to some suggested language, that will get my appeal juices flowing.  I will try to do some searches here, (although I am sure the search engine is not any better) and will look on dsfacts.....

T
DarcyMad
on 11/4/11 4:19 am - Cedar Park, TX
Travis!!!  I was just thinking about you the other day.  Sounds like you are struggling and I'm sorry to hear that.  Yes, Diana or Larra are both good contacts for that kind of thing.  I'm sure they can help you.  Surely you have a case against the insurance company.  I have Aetna too but didn't have any problems with my approval.

Catch me up!
DarcyMad
Surgery Date:  11/15/2010
Jewel506 is my Angel!    Angel to Kristi (Momx4)
Anything that is, or was, began as a dream - Lavagirl 
    
travis1985
on 11/4/11 6:18 am - TX
Hi Darcy, how are you.  It looks like you have had a great year.  You are rocking it, as they say.
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