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RoseMary D.
on 2/5/13 5:29 am - Port Orchard, WA
Topic: RE: Obesity Lawyer
Please send me the attorneys number, I had it once back in 2008 when I had to have a revision. He was great, I now have a friend that needs her gastric band removed but insurance won't pay for it. I want to provide her with the attorney so she can go forward.
noftessa0401
on 2/5/13 4:06 am - San Diego, CA
RNY on 12/27/12
Topic: RE: Aetna Appeal Letter

Sorry to hear that.  I guess your only option would be to have your doctor write a letter asking them to expedite the appeal process for dire medical reasons, and then explain the hernia.  Hopefully it won't take the full 8-12 weeks.  I wish you luck!

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

eljefej
on 2/5/13 4:04 am - alexandria, VA
Topic: RE: Aetna Appeal Letter

They said they will not accept any new information, I did go in again this month on the 31st which would technically give me about 120 days but she said my only option is to do an appeal at this point.

noftessa0401
on 2/5/13 3:35 am - San Diego, CA
RNY on 12/27/12
Topic: RE: Aetna Appeal Letter

I am not sure you can get them to expedite an appeal.  It certainly wouldn't hurt to try it, but I'm not sure of the process.

Instead of appealing, can you do 3 more days of the program, and then resubmit your paperwork to Aetna?  That might be faster.  And, I have heard that Aetna is notorious for being strict about the 90-day program - so I am not sure where the doctor's office lady gets her info.  They want at least 90 days.  If you can see a doctor now, and have them write down your current weight, what you've been doing since the 88th day of the program, and document your vitals, maybe that will be enough to qualify for the 90 days.  The 90-day program does not have to be a specific "program" per se, there are just certain criteria that need to be met, and you need to be dedicated for at least 90 days.

Good luck!

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

eljefej
on 2/5/13 3:31 am - alexandria, VA
Topic: RE: Aetna Appeal Letter

I am not sure, I think the lady at the doctors office wasn't really trying to do her job.  She just called me back and said she talked to Aetna and they said it was denied because I did 88 days and not 90 and that now I have to send in an appeal letter.  She said they have never seen them be this strict before and that this has never happened.  So now I need an appeal letter example and need to know how to get Aetna to expedite it.

noftessa0401
on 2/5/13 2:16 am - San Diego, CA
RNY on 12/27/12
Topic: RE: Aetna Appeal Letter

What do you mean by "that my plan does not cover me doing a 90 day program?"

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

eljefej
on 2/5/13 2:15 am - alexandria, VA
Topic: RE: Aetna Appeal Letter

Thanks for the info.  The 90 days would have been up by the time my surgery was suppose to be in December, they are actually asking for a 3 yr weight history which is now moot because I had a weight taken this year which gives me 3 years of weight history now.  The issue now seems to be that they are saying that my plan does not cover me doing a 90 day program which makes no sense because that is not what they told me when I called before and during the process.  Aetna is telking me the only thing I can do is have the doctor do a peer to peer or do an appeal.

noftessa0401
on 2/5/13 2:13 am - San Diego, CA
RNY on 12/27/12
Topic: RE: Can I be refuse

What does your insurance policy say?  Each insurance company issues many different types of policies, with each policy stating different requirements for getting WLS. 

Most insurance companies require a certain BMI, a certain amount of time of that BMI history (usually 2-5 years), and some require a diet/program to follow before they will authorize WLS.

Usually the BMI must be at least 40, but if you have co-morbidities (like high blood pressure, sleep apnea, etc.), then your BMI could go as low as 35.  However, if you don't meet all of the requirements your insurance policy dictates, then, yes, they can refuse to authorize your surgery.  Just having the co-morbidities does not make the surgery a medical necessity.

Good luck!

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

noftessa0401
on 2/5/13 2:10 am - San Diego, CA
RNY on 12/27/12
Topic: RE: Aetna Appeal Letter

Unfortunately, Aetna is that strict (at least regarding the 3-month/90 day diet).  It really needs to be at least 90 days (I did mine for 100 just to make sure).  I am not sure what you mean by your plan not covering a 90-day program - mine didn't either, so I paid out of pocket for one - it was worth it to me.

If you don't have the 2-year weight history, there is not much that can be done right now, at least as far as appealing Aetna.  That is their requirement, and they are entitled to set their requirements.  This requirement is pretty common for most insurance companies, so it is not outrageous, egregious, or arbitrary.  How close are you to meeting the requirement?

As for the 90-day plan, keep going - don't stop.  If not more than a month has passed since you last saw a doctor for the diet/program, you should be able to keep going and have it count towards the 90 days.  One more visit ought to do it, and then you can resubmit.  At least as far as the 90-day program goes.  This won't help your weight history, see above.

It really sounds like you need to get your hernia repaired, and then worry about qualifying for WLS.  I'm not sure that Aetna will see the two as being related.

Good luck.

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

cajeal
on 2/4/13 10:07 am
Topic: Can I be refuse

If I meet 2 of the requirements like high blood pressure and sleep apnea can my insurance co refuse surgery , wouldn't it be consider a medical necessary then

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