I'm so confused!

I have been denied by Aetna. I am needing to file an appeal because my doctor doesn't. Aetna sent me a form titled 'Request for a review by an independent reveiw organization'. Is that what I'm suppose to fill out? And what else do I submit? I have none of my records. Help me please?

First, why did they deny you? Do you have a BMI of at least 40 OR a BMI between 35-40 with a co-morbid condition such as diabetes or HTN? Did you provide a 5 year weight history showing persistance of the above BMI/co-morbid requirements? Lastly, did you have either a 6 month physician supervised diet with your pcp OR a 3 month pre-surgical preporatory program with your surgeon? If all of these were met, and the documentation was submitted, you shouldn't have to appeal. I can try to help you, but I need more information.

The letter had the entire section copied from the Aetna criteria. So I'm not sure if they are denying me for all of it or part of it. But yes...I have a BMI of 39 with co-morbidities. I now have a BMI of over 40 and I have sleep apnea. I also saw a doctor for diet and exercise. I am guessing that part of the denial was because my surgeon sent everything in before my last appointment. I had seen the doctor 6 times, but the time between the first and second appointment was more than a month, so I had to go one more time to make in six consecutive months. I had all my records showing a past history of obesity. I guess I was thinking the letter would be more clear as to what they wanted from me. I have written a letter addressing all the criteria. I plan on sending copies of my records to prove it. Is that all I need to do? I really wished my doctor's office was more helpful....

That is a general letter, but your doctors office could and should speak to someone to get clarification. And if they're the ones that submitted the information, they should be helping and making sure that the insurance company has all the information that they require. What I would do, is call your doctor's office and have them call Aetna to find out specifically what was missing. If there is additional information to be submitted as you have indicated, then they should be able to just fax it without going through any appeals process. If they seriously won't help you with that, not only is that a load of BS, but you'll have to get a hold of your medical records and submit the stuff yourself. Compose some sort of simple letter stating "Here is the additional information per your request." You need to find out exactly what your doctor's office sent. Try to obtain fax #s and any names. They are basically not finishing what they started, and without this information, it's very difficult to find know what Aetna still needs. Another avenue to pursue is to call the cust service # on the back of your card and try to be transferred to the case managment dept. Honestly, though, you need to get on your doctor's office because this is not yet an appeal situation. It's their fault if they didn't send in the required documentation. Are you even sure that they documented your phys supervised diet well?