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I desperately need help with an appeal letter. I currently have a hernia and need surgery ASAP for it. I went thru a 90 day program with the hospital but now Aetna is denying me for surgery. The letter says it was because I did not have 2 years of weight history and I did not have either a 6 month diet plan or a 90 day program. I did the 3 month program with the hospital but it was not technically 90 days the hospital is telling me that shouldn't matter and that Aetna is never that strict. Problem is each week my hernia gets bigger and I need the Gastric surgery to help me lose weight so it does not come back, I just had surgery for a hernia last March. When I called Aetna they told me that it was denied because of my weight history and not haveing a 90 day program like the letter says but the doctors office is telling me that they are being told that my plan does not cover a 90 day plan and that I need to do more than 90 days. I am telling them that the letter does not state that and I have even sent them the letter and they say they understand but they cannot make Aetna approve the claim. They feel like they are just trying to deny the claim for some reason. Any help anyone could provide would be greatly appreciated, I feel like my only course now is to file an appeal but they told me an appeal could take 8-12 weeks and there is no way I can wait that long to have my hernia surgery. Does anyway also know of a way to get an expedited appeal?
Thans for any help
~ CJ Bradley - Lapband Surgery 7/2007 with many complications. 2012 Seeking Revision to RNY. 2013 Revision denied. Trying to work with band.
Congrats Sara! I have UHC as well just waiting for my approval stuff was sent in Jan 24th and more Jan 28th well the rest of it.. i am calling Monday to get an update. 
HW: 401 SW: 297 CW: 200.8
RNY gastric bypass surgery on March 5th, 2013
I got approved! Wait was 7 business days! Yipppee!
- Geneen Roth
Apparently their denial is typical on first-time requests like these. Here is a link to an attorney (advocacy group?) that did a 2nd level appeal to Cigna and the revision was approved. This was a while ago, but I imagine that the principles are the same.
http://wlsappeals.com/bariatric-insurance-denial-revision-ap peal/
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)
Collette
They said there is nothing mechanically wrong with my band. 
Which there isn't. It's everything else thats seems to be wrong.
HW 300, SW (Realize Band) 268, Revision to VSG 264
My surgeon submitted for approval on Jan 24th. I called my case manager on Monday and my case hasn't even been reviewed yet. She told me to try again next Monday i am so stressed and my anxiety is high waiting for the approval. I don't see why i wouldn't get approved though,, bmi has been over 50 for well over 7 years.. sleep apnea, pre-diabetes, did 6 months of monitored weight loss with nutritionist, etc
I have UHC my case manager said it could take 10-15 business days my surgery isn't until March 5th anyway and this is why my surgeons office schedules this far out for these reasons. How long for anyone who filed recently through UHC did it take to get approved??
HW: 401 SW: 297 CW: 200.8
RNY gastric bypass surgery on March 5th, 2013
I don't have much experience with Cigna, but what was the reason for the denial?
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)
Has anyone ever appealed to Cigna and won? I have a Realize Band and had to have an emergency unfill in December. Since then I have had a lot of acid and heartburn. My doctor sent me over for an upper GI and my band is in perfect position. I haven't lost ANY weight since April of 2011. The last few months have been fill to be unfilled the following month. This is frustration, I am hoping to revise to the sleeve.
I would appreciate any help offered.
Thanks
Andrea
HW 300, SW (Realize Band) 268, Revision to VSG 264
Hockeymom87 · 0 replies · 727 views
