Aetna Denied Me

I turned in all of the required paperwork: including  Psych Eval, 6 month supervised weight loss, Letter from my PCP, Letter from my chriopractor (though it might help), and my 5 yr weight history from my PCP.   I was denied because over the course of my 5 yr weight history my BMI fell below 35.    Aaaaaaahhhhhhhhh!!!!!    Now what?  Can I appeal this?   Perhaps give a history past 5 years? If you are interested, here is a bit more info about my situation: I am 29, 5'3", 220lbs with a history of hypertension.  I have been overweigh since my teens, so I have attempted many diets and exercise programs but I have never been able to maintain my weight loss (as have most of us).  So as the years go by my weight yo-yos with each weight loss attempt.  My most sucessful weight loss attempt was when doing Weigh****chers 2 years ago, but alas all of the weight has returned.  Of the top weights recorded by my PCP over the past 5 years, one of them fell below a BMI of 35.    Any thought, suggestions????

I am so sorry about the denial.  I just finished my 6 month diet - saw a nutritionist, bought a gym membership, see a therapist and my PCP.  They approved me in just a couple of days - I don't have any co-morbidities and my BMI is 42.1.  They never asked for a 5 year history -is that something new?  I have Aetna POS - I'd be interested to know what happens - Good luck!!!!  I know how hard it is.

I just have to say that I am looking in a mirror!  We are the same and I just got denied for the 3 rd time, one with Tricare, one with Aetna and one over the phone when my surgeon called Aetna.  I was the same thing, I was below 35 3 years ago!!!!!  After doign WW for about 6 months.   They are appealing it, but I think it is a lost cause.  I have been doing this for the last 9 months and I am just drained!  I know exactly where you are coming from!!!  Are we suppsed to wait 5 years and then try again, when we DO have diabetes, and hypertension????  IT is so crazy!!  If you need to talk just message me......I am 5'4 233....I have been yo-yoing from 222-233 for about 2 years.....I have had gestational diabetes with both of my kids and I have arthritus in my back...im a mess...lol Well, good luck and keep me posted!

First off, you don't need to submit a 5 year history.  I just got approved from Aetna.  This is what I did: 1.  Saw my PCP for three straight months.  She monitored my weight knowing what I wanted to do, which was to have surgery 2.  Saw a nutritionist for three straight months.  Same as above. 3.  Went to a surgeon with my records. He submitted the info and tada..DONE.  I got approved.   Of course, my BMi is much higher than yours..but still...according to their own policy, you don't have to send in the 5 year medical history.    Deana

I am so confused.  In the Aetna policy the first line does say that there needs to be a bmi over 40 consecutively for 5 or more years.  I was not.  That is the only reason why I got denied.... Maybe we have different Aetna policies.  Or it changed.  Please tell me im wrong...

Here is the link to Aetna's Policy regarding any WLS:  http://www.aetna.com/cpb/medical/data/100_199/0157.html It does state that a 5 yr weight history is required.  It does say that you BMI must be >40 or >35 with co-morbities.  Under the background section it lists the rationale for the 5yr history as:  "Obesity surgery is not indicated for persons with transient increases in weight (Collazo-Clavell, 1999).  According to the Guidelines of the American Association of Clinical Endocrinologists and the American College of Endocrinology (1998), “Surgical treatment of obesity may be considered only in carefully selected patients [where] … obesity has been present for at least 5 years.” I intend to appeal: just because my weight dipped below a BMI of 35 while I was trying to lose weight (like we are supposed to) it still failed and I am still fat, with high risks for more problems in addition to my current ones.   I intend to state that my weight is not just a transient increase (since I have had a BMI >35 for the other 4yrs I submitted).  If my PCP has more records, older than 5yrs, I will try to provide a longer history showing a BMI >35 for perhaps 7, 8, or 9 yrs (what ever they have).  I think I will also average my weight over the 7-9 years and state that I had an average BMI >35 during those years. I hope that would be enough.  I am not sure what else to include in my appeal.  Any thoughts? Ellen, what did you put in your appeal?  Why did they deny you the 2nd time?  Same reasoning?  What did your denial letter say specifically?

How is your appeal going?