Aetna Denied....please Help

Ok... I got my (1st) denial letter.  It says " based on the information provided by the requesting physician, you do not meet the established medical necessity criteria or guidelines for the service requested at this time", "Specfically, the service requested was reviewed by our physician reviewer.  The medical documentation received does not support the need for this service because patient does not meet medical criteria."  OK.....this is a good thing right....it means my insurance (job) covers it but that my PCP did not put the correct (or enough) medical info?  What do I need to do now.  DO I NEED TO FILE A GRIEVANCE or just RESUBMIT MY REQUEST?  I hope I only need to resubmit my request with a "juicier" letter.  How long should I wait to resubmit?   HELP.....  I need some comfort food.  Thanks for listening........HELP... Sonja

It says patient does not meet medical criteria... What exactly did your surgeon submit? Did they include all co-morbidities & how is your BMI? I didn't go look at your profile to see if it was listed. That is where I would focus my attention, into finding out what their medical criteria is, find out what part of it you didn't meet & then find out what information  you can resubmit to show that you do meet that medical criteria.  Make sense? Good luck. Let me know how it goes for you. Jenifer

I am in the process of requesting a copy of the letter my PCP sent.  I am going to appeal.  My BMI is 37.7 but my knees hurt like hell and I have back pain and arthritis along with stress incontinence.  My BP is ok and I don't have diabetes but I have a family history of both....oh well.

Is there any chance that you may have sleep apnea? I didn't have a clue what it was until after I started researching this surgery. My PCP suspected that I had it when I told him I was waking up 5/ 6 times a night and very tired in the mornings + I snore. Did sleep study & sure enough I have a severe case of it. That might be worth checking out. I have heard the insurance companies don't take notice to co-morbidities of legs/ back hurting as much as the ones with labels and that put you at risks. The other thing I think I have had for a while but was just diagnosed with Monday is GERD- reflux disease. I eat tums like candy and I just never pursued getting a diagnosis of it from my doc. Just some things to check into. I would definitely do as one of the other posters suggested- ask for a copy of what was submitted by your doc and see if there is information that is missing. It could just be a matter of resubmitting additional info. Jenifer

I would go to the physician and ask for a copy of all that was sent to the insurance company. I had done that and was shockingly supprized and the lack of detail my office had send in. I am appealing my denial and doing it on my own with a lot more detail and physical eviedence of co-mobities. Sorry that this is not much help but it was an eye opener when I saw what they send compaired to what i though the had sent GOOD LUCK! best wishes:) Tamara