NuttyMoonBride

APPEALS, APPEALS, APPEALS .....

44 posts in this topic

Greetings:  

 

Has anyone done the 1st appeal, 2nd appeal, and external review. 

 

ON 9/25/13 I was denied by AETNA, and the peer to peer review due to insufficient medical history of morbid obesity, BMI over 35 and a co-morbid condition.  In my case, Obesity for 6 years, BMI 38.4, hypertensive, depression and hyperglycemia.  My PCP, provided my surgical coordinator with 3 years (53 pages) of medical Hx documenting the above Dx to be sent for an appeal.  My Question is, how difficult or how challenging is a 1st level of appeal?  

 

Suggestions, are welcomed  :)

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No advice but wanted to offer good luck! Hopefully someone chimes in!

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Hello, I'm not sure but it looks like we are in the same boat.  My paperwork was submitted today for the first time and the doctors office told me my changes of approval are slim, because my BMI has not been above 40 for 3 consective years.  I'm so frustrated and I'm in the process of starting my appeal letter just in case.  Good luck to you!!!

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I may be joining the appeal process due to the fat that my insurance has already contacted my surgeon and they were not happy with the PCP's note for month 1, 2, 4, & 5 still waiting for the insurance company to make it official. If they deny me I am appealing and requesting a peer-to-peer review with my PCP as he said that he can not amend his prior notes, but he feels there is enough documentation to support it.

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Greetings to All:   

 My first denial and the Peer to Peer was due to a BMI of 38  and documentation that did not indicate persistent morbid obesity of at least 2 years with any of the 3 life threatening comorbid condition. On 10/4/13 I mailed Aetna  53 pages of medical notes reflecting obesity, BMI and plenty of different medications to control my blood pressure.   Aetna has 30 days to make a decision.  I will continue to appeal until the External Review Organization makes the final decision, then I may quit.  As for right now, it is just a day at a time. 

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so how long does the 1st appeal usually take? I just called to check on the status to see if mine was still pending and they called the reviewers but no answer.

ancrowl likes this

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Any news on your approval?

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United Healthcare said they allow up to 30 days to process appeals. Mine took just a couple days short of that.

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I have aetna ppo & was denied at first then did the 3 month with psy & nut & then resubmitted & then aetna wanted my weight from 2 years ago. My doctors office submitted everything & I was denied again, so we sent aetna previous failed weight loss attempts at programs dating 2009, 2010, 2011 & 2012 & they denied again! My doctor has a peer to peer with the medical director on Tuesday. I've been so emotional through this whole process. Aetna basically is saying I haven't been fat enough long enough.

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I don't think that is what Aetna is saying and you need to find out exactly why they are denying your requests. You have to clearly define a problem before you can solve it.

Ash_xoxo_xoxo likes this

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I keep hearing Aetna has been denying people. My case is being reviewed now. I'm trying to stay positive. I would have a heart attack if they deny me.

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Hey, Cal; you wont have a heart attack. You have to stay focused and determined.  But most importantly, you must be ready to advocate for yourself.  Aetna is taking its sweet little time reviewing my 53 pages of 3 year history of weight related issues.  In as much as I would love them to hurry up, I must be patient and so should you.  We've come so far for this.  I've realized that worrying does nothing positive to our Karma, on the contrary, it fills us up with anxiety, uncertainty and desperation in conjunction to exacerbating our physical and mental health.

 

Stay positive.   Faith and Hope are your real Best friends. ;)   

Cali2AK and dorie like this

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I may be joining the appeal process due to the fat that my insurance has already contacted my surgeon and they were not happy with the PCP's note for month 1, 2, 4, & 5 still waiting for the insurance company to make it official. If they deny me I am appealing and requesting a peer-to-peer review with my PCP as he said that he can not amend his prior notes, but he feels there is enough documentation to support it.

Hey Samelton, any word yet?  

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Hey Samelton, any word yet?  

I am appealing, just talked to the person handling it today looks like it will be the end of November before I know anything. We are submitting medical records dating back to 2009 showing that I have been morbidly obese and then I have requested my PCP write a letter to the appeals committee stating why it is medically necessary and that I have been seeing him more then 6 months discussing diet and exercise at each visit. I also wrote a 3 page letter expressing my opinion.

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I am appealing, just talked to the person handling it today looks like it will be the end of November before I know anything. We are submitting medical records dating back to 2009 showing that I have been morbidly obese and then I have requested my PCP write a letter to the appeals committee stating why it is medically necessary and that I have been seeing him more then 6 months discussing diet and exercise at each visit. I also wrote a 3 page letter expressing my opinion.

That sounds about right.  My appeal was submitted on 10/8/13.  Aetna has  30 days to inform you of a decision.  It's funny, but I never wrote a letter stating why they should overturned their decision.  My surgical coordinator, did not think it was necessary since she only submitted the 6 months medical weigh in notes, and all of the required test, to do the surgery.  Therefore, denial letter stated:  "That the information submitted by my Dr.  did not demonstrate 2 yrs of persistent obesity with a BMI of 40 or 35 with any of the life threatening morbid condition; hypertension being 1 of them.  My PCP provided 53 pages of medical history, since 1/2010 which shows literally, monthly visits to address my hypertension, obesity and hypercalcemia. I don't want to sound overly confident, but I think my PCP, provided enough evidence.  Well, I'm hopeful, and super determine to keep appealing. 

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Turnthepage ; aetna is saying the reason I was denied was because my bmi wasn't high enough two years ago but I was going to lindora (weight loss clinic) 09, 10 , 11 & 12 on & off. I always gain the weight back & then some. It's not like all of sudden I was like I'll have surgery it's been a long process before even coming to yhe decision I want it & now that I do. Aetna isn't helping. I'm very worried about the peer to peer. Will aetna overturn there decision even though my bmi wasn't high enough for them two years ago? Any comments?

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Aetna is relying on the fact that your BMI has not been consistently above a certain level for at least 2 years.That strikes me as odd, because many dieters have a yo-yo history. However, it does make sense from the standpoint of preventing someone who has recently gained a lot of weight from having surgery without trying more conservative weight loss methods or without thinking through the required lifestyle changes. It comes back to the issue of medical necessity, which you appear to have well documented. 

 

The peer to peer review is a good thing because it will be 2 doctors talking to each other, rather than staffers or nurses dealing only with the paperwork in front of them. If 53 pages were sent, I have to wonder if the staffer read and understood all of it. No way to know how competent or diligent the review was, so I think peer to peer is a big plus for you.

 

You might ask your Case Manager for Aetna's Statement of Medical Policy for Bariatric Surgery or whatever they call it. These statements are the insurance company's own internal guidelines for reviewing requests for surgery. They may be reluctant to give it to you or say there isn't one, but that's nonsense. Underwriters must have guidelines in order to do their job in assessing your request. By getting my insurer's statement I was able to dig down and discover my doctor's office had screwed up on my requirements and I was able to find a workaround that won the appeal. It was a very nerve-wracking process. Wishing you all the best!

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Hey, Cal; you wont have a heart attack. You have to stay focused and determined. But most importantly, you must be ready to advocate for yourself. Aetna is taking its sweet little time reviewing my 53 pages of 3 year history of weight related issues. In as much as I would love them to hurry up, I must be patient and so should you. We've come so far for this. I've realized that worrying does nothing positive to our Karma, on the contrary, it fills us up with anxiety, uncertainty and desperation in conjunction to exacerbating our physical and mental health.

Stay positive. Faith and Hope are your real Best friends. ;)

I know I need to stay positive. I've done everything in my power to do everything in the cpb. There's no reason that they would deny me but it seems they're being difficult nowadays. But you're right, faith and hope ... Thanks for having my back and keeping my eye on the prize. :)

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Update:   I got a card in the mail stating: 

"  Dear Valued Aetna Member:  Thank you for contacting Aetna!  we have received your request fir review/appeal and will be responding to you soon.  

Please note that you may also call Member Services at the number on your member ID card if you have questions."  

At least is relieving to know that they've received my request for an appeal.   it has been 18 days since my request was mailed in.

 

I will keep you all posted.    :)

Cali2AK likes this

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Well at least you received that, did it give you any other information? I know when I contacted BCBS of MN they said they will take 30 days and that I can submit more information, give verbal testimony and that they will send it to an outside review panel.

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Well at least you received that, did it give you any other information? I know when I contacted BCBS of MN they said they will take 30 days and that I can submit more information, give verbal testimony and that they will send it to an outside review pane

Hey  Sorry for the delay.  

No more information was given. But I know Aetna has 30 days to make a decision. I think it is an Insurance regulation.  It is the same process, as BCBS,  If i get denied I can request an external review. Which I am planning on doing.  Let  Be hopeful.   :)

Edited by NuttyMoonBride

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I find that I am loosing faith and motivation that I will ever have this surgery while I wait for this appeal to be determined. I spoke to a paid advocate and they said I will probably be denied on this and have to go to the next step which is the appeal hearing, they charge $900 to handle the appeal hearing.

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Please check with at least a couple of advocates/attorneys to get the best rate and check their win/lose records.  Wishing you all the best!

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I find that I am loosing faith and motivation that I will ever have this surgery while I wait for this appeal to be determined. I spoke to a paid advocate and they said I will probably be denied on this and have to go to the next step which is the appeal hearing, they charge $900 to handle the appeal hearing

Hey!! 

I must agree with you.  I just got Aetna's decision of denying my first level of appeal, despite of submitting 3 years of medical notes with persistent obesity related issues and hypertension as a disease., which documents all the different meds that have been on to control my blood pressure. The denial letter reads like this:  "there is la lack of documentation in the medical records of at least a 2 year history of obesity  with a  BMI of more than 40.  Alternatively, the member can have a BMI of 35 for 2 years along with one of the following diseases:  1) diabetes 2) high blood pressure that is not well controlled with medication or 3) Sleep Apnea that meets the guidelines to wear a CPAP  or 4) Disease in the arteries of the heart."  

 I honestly don't know what else to submit to them.  I can have a second level of appeal which I will be doing.  But really, isn't it cost effective for them to pay for the surgery than to be paying for cardiologist and pcp's visits on a quarterly basis?  

Any suggestions will be welcomed.  :)

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Hey!! 

I must agree with you.  I just got Aetna's decision of denying my first level of appeal, despite of submitting 3 years of medical notes with persistent obesity related issues and hypertension as a disease., which documents all the different meds that have been on to control my blood pressure. The denial letter reads like this:  "there is la lack of documentation in the medical records of at least a 2 year history of obesity  with a  BMI of more than 40.  Alternatively, the member can have a BMI of 35 for 2 years along with one of the following diseases:  1) diabetes 2) high blood pressure that is not well controlled with medication or 3) Sleep Apnea that meets the guidelines to wear a CPAP  or 4) Disease in the arteries of the heart."  

 I honestly don't know what else to submit to them.  I can have a second level of appeal which I will be doing.  But really, isn't it cost effective for them to pay for the surgery than to be paying for cardiologist and pcp's visits on a quarterly basis?  

Any suggestions will be welcomed.  :)

If you want to call and talk to the advocate I spoke with here is their info:LINDSTROM OBESITY ADVOCACY 

601-C East Palomar Street, #480

Chula Vista, CA  91911

WWW.WLSAPPEALS.COM

Tel:  619-656-5251

Amber76bailey likes this

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