NuttyMoonBride

APPEALS, APPEALS, APPEALS .....

44 posts in this topic

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

 

Thank you for the information.  your help was really appreciated. But check this out ..

My employer is linked to Medical Link due to my company's insurance carrier, Oxford.  I dont have medical coverage through my employer, since I'm covered under my husband 2 Aetna's plans.  So I took my chances and called them ( MedicalLink).   Well, well, well Guess what I found out, according to medical link representative, in NY state, once a second level of appeal is filed with Aetna,  your rights to appeal at the state level aka External review are automatically terminated. I WAS SHOCKED.    She encouraged me to go straight for the state appeal, because the likelihood of Aetna denying me at a 2nd level is very high.  Aetna is known for their low overturn rate.  

I analyzed  her recommendation and realized that the medical link representative is the only person is unbiased and who has no gains from this entire ordeal.  why?  well, im not covered under Oxford,  so she is not protecting Oxford's interests.  She surely does not work for Aetna, so she is not protecting their interests either and  she is not working for my surgeon who gives 2 cents if I get approved or not.     I will contact Aetna to find out if my rights for an external review get relinquished once I file a level 2 appeal, and if so, I will go straight to the state appeal/external review, the highest and last appeal level one can go. 

Edited by NuttyMoonBride

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Kelly Lindstrom at the Lindstrom law office was extremely helpful in explaining the state appeal process to me during my appeal process. It was done as part of the free consultation. If you talk with Kelly or someone like her that knows how your state's appeal system works, you can save yourself a lot of time and aggravation--and possible save yourself from making an error that blocks your surgery. Good luck!

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I need to go into the business of appeals, It is an organized system.

Newstart2014 and samelton68 like this

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Man! I can't believe they are doing this. It almost makes you wonder if certain plans depending on employer is the reason it's harder to get approved. We just found out that 4 of my husband's coworkers had bypass surgery in the last year. All paid by Aetna-Costco. I'm still sending prayers your way for an approval.

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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.

I had to file an appeal with BCBS for my revison from band to RNY. It took 3 1/2 weeks for an answer.

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Greetings: 

well, not much here.  i contacted Aetna's external review unit to find out if I will lose my rights for a state level appeal, I was told I wouldn't since Aetna is not an insurance at the state level, but federal; therefore, I should follow their guidelines and go through the level 2 appeal.   I will be filing it.  I requested my medical history from my hospitalizations since 2004-present, there, they will see my high risk pregnancies (2) that were induced at 34 and 32 weeks of gestation due to my high blood pressure. I really don't know what else to do.  I am a devout christian and it is my believe that when one door closes is because a much better and greater one opens, because the Lord has a purpose for us in life.  This whole entire ordeal, is really testing my faith and even though I am aware of it, I feel conflicted.  This insurance thing, it's taking an emotionally toll on me. I don't want to quit, but I cannot deny that I am losing hope.  :(

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I was wondering for those of us going through the appeal process:   Could it be that Aetna is becoming more difficult due to the Obama Care.   I've noticed that all my Aetna correspondence contains documentation regarding the Affordable Care Act ( ObamaCare.)  Honestly, My Dr. believes that with all the medical documentation we've submitted, my surgery is medically necessary, however,  Aetna does not think so, since my blood pressure is control, thus denying it as " being controlled equals not medically necessary at this time.  He believes that this is a diversion, to push me into next year and see how the ObamaCare will affect those who are "controlled" or managing their illnesses.  

Do think it is possible?   ANY suggestions will help? 

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The Advocate said they aren't that smart, as I suggested maybe they were denying me until next year so I would have to meet my deductible and max out of pocket again

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I won my appeal, it has been decided that it is medically necessary!!!!!! YAHOO

TurnThePage and Cali2AK like this

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Super Frustrated with Aetna :angry:   :mellow:  :mad:  

 

I went to my cardiologist for follow up appointment.  I was just told by her that despite of having my blood pressure controlled, my heart rate is extremely fast.  When she asked me about the WLS showed her Aetna's denial letter that states: "Due  patient'ts controlled Hypertension, bariatric surgery is no longer medically necessary at this time."  She was flabbergasted and decided  to write me a 3 page letter with the final conclusions and findings that states the following: " Despite of my patient's improved blood pressure, as a cardiologist I am concerned that my patient may develop a dilated cardiomyopathy without weight-loss surgery.  I strongly recommend weight loss surgery to prevent further complications related to hypertension and obesity.  In that letter she outlined my diagnosis as per the hospital's medical records and as by her records since she's been my cardiologist for the past 3 years who recommended the surgery and wrote the initial letter of medical necessity.   

Hypertension

Hyperglycemia 

Depression, 

Hystory of Pre-eclampsia-Delivered 2x 

Hemangioma of the left Kidney

Hyperparathyroidism/ parathyrodectomy on 3/11/2013.

 

Please keep in mind that with the exception of Depression and all other diagnosis are related to hypertension.  

She told me that if Aetna does not approve the surgery with that she does not know what else they may want. 

 

If this level 2 Appeal gets denied, I will give up on pursuing this surgery. 

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When did you turn that in? is it a 30 day wait on this?

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When did you turn that in? is it a 30 day wait on this?

Hi   :)

It was turned in 1 week ago. Aetna has 30 days for a decision.  if the appeal is not overturned, I can have an external review.  

It is frustrating and depressing.  for this appeal, my surgical coordinator submitted my hospital medical records for the past 8 years along with my medical record from my PCP from 1/2011-10/4/2013, which he gave me a copy of. 53 pages all detailing hyperglycemia, hypertension, obesity and multiple medication changes and calibrations and Aetna is not even considering.  

I am a devout Christian and I beginning to think that maybe it is not my time for the surgery.  I never thought I was going to say this, but if this doesn't work, I will let it go.  :)

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Nuts to the idea of giving up.  I don't buy this 'meant to be' crap.  You were given the gift of free will, so use it to pursue what you know to be the right path for you!!!!

NuttyMoonBride likes this

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Hi :)

It was turned in 1 week ago. Aetna has 30 days for a decision. if the appeal is not overturned, I can have an external review.

It is frustrating and depressing. for this appeal, my surgical coordinator submitted my hospital medical records for the past 8 years along with my medical record from my PCP from 1/2011-10/4/2013, which he gave me a copy of. 53 pages all detailing hyperglycemia, hypertension, obesity and multiple medication changes and calibrations and Aetna is not even considering.

I am a devout Christian and I beginning to think that maybe it is not my time for the surgery. I never thought I was going to say this, but if this doesn't work, I will let it go. :)

Although at times we may not understand but everything happens in God's time. Don't let it go but look to Christ for guidance in repairing your health. Either by wls or possibly other means. I know this has been a difficult time for you. 《HUGS》

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Don't give up!

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It has been 7 weeks since my level 2 Appeal was submitted to Aetna and they have not processed it.  I don't want to give up, but I started this process in April 2013, and was with the 2 appeals that I have had, It has been 9 months since this journey started.  Why does it take so long for Aetna to take my PCP and Cardiologist necessity recommendation for this surgery, especially since i am at a higher risk of developing a dilated Cardiomyopathy.  I don't want to stop taking my blood pressure meds, but if having it controlled is causing me not to get approved maybe I need to have a 2nd heart attack for them to approve it and to understand that if it is really controlled is because of the two medications, i'm taking at the moment.   I am just feeling blue and disappointed.  Any suggestions.  Thanks. 

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Keep pushing. Most of the insurance companies think if they fight you long enough you will just go away. I started my journey in October 2011. It took me two years to get operated on but it eventually happened.

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I  GOT APPROVED.  .  

 

Lindstrom Advocay Group  has won AETNA's EXTERNAL appeal.   The IRO IMEDIC overturned Aetna's denial.  EXCITING !!!  

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I'm aware this is an old forum, but I'm just like many out there searching for answers & updates, so here I am. I happened to finally find this one (maybe old, but was helpful). I wanted to share my experience. 

My journey started back in March of this year to make a change. I had suddenly became way overweight and unsure as to why until now after so much research.

In 2010, I weighed 150lbs and I was happy even if I was still 30lbs overweight. Then all of sudden I experienced so much pain during my menstrual periods and having cysts develop in my tubes & ovaries. October 2011, I weighed in at 160lbs and gaining. No clue as to why. Fast forward, I was diagnosed with Stage 4 Endometriosis. I am now 210lbs. The combination of medications and my disease caused my weight gain. 

I started doing my research as to what was required to be qualified for WLS. I already had 1 of the requirements for Aetna-I had a BMI over 40 (41.2)-I started seeing my dietitian for consults as stated on preoperative regimen of Aetna's policy; 3 months and no net weight gain during the program. 

Easy?! Yup, it was. Or I thought it was easy enough to get an approval. 

I weighed in starting at 211lbs in June (the beginning of the program). I seen my PCP, my surgeon and my dietitian every month and weighed in each time. I'm a nursing student so the only available time I can go in is late afternoon.  I weighed in around 2:30pm-430pm at each appointment and each time the scale went up. Why? Because I was weighed in with all my clothes & shoes. Aetna denied me twice. The first denial (July 27th) was based on the 90 days consultation with the dietitian. Ok cool, I had only 70 days out of 90 days. August 23rd, I weighed in at my surgeon's office at 218lbs @ 2:30pm. Went to see my PCP at 4:30pm weighed in 214lbs with my undergarments on and a paper gown. I knew it was because of the undigested food still in my system. 

Notes submitted to Aetna. I already knew it was going to be bad. 2nd denial (September 9th) based on a net gain of 7lbs during the program!

GREAT! I knew it. As soon as I got off the phone with the insurance, I called my PCP and requested a weight check appointment at the earliest time they had available in the morning because the most accurate reading is in the morning after everything you ate has digested in your sleep. I came in at 7:45am on September 16th and weighed in at 210.8lbs!! A real big difference. 

I wrote a letter addressing the inaccuracies on weighing me in during the late afternoons and fully clothed with shoes. I wrote a letter for the second level appeal & so did my doctor's office. The second level appeal letters were sent to Aetna on September 19th. I called everyday...I mean everyday and so did my doctor's office. I called on September 29th and Aetna reversed their decision and approved my surgery. 

So, thanks to NUTTUMOONBRIDES story I felt confident they were going to approve it. 

I hope my story helped you. 

Cheesehead likes this

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