Appeal Process With Aetna And Lindstrom Advocacy

[Mandylove 32]

Hi all,

I was recently denied by Aetna for lapband due to not having a high enough weight for 2 years. My problem was that I lost some weight on a supervised diet (Jenny Craig) and then gained it all right back, so the insurance company denied me for having once lost weight. I have now developed a thyroid problem which makes it that much harder to loose weight. In saying all this, I am working with lindstrom advocacy to hopefully get it over turned. Has anyone worked with them having Aetna and had success. I'm very discouraged and want this really bad! Any information would be greatly appreciated

-Mandy

[Maddysgram 6,159]

My Aetna went back 5 yrs. I've lost 100 lbs twice but records showed I always gained it back. Good luck with your appeal. Hope it works out for you.

[newme37 16]

Make yourself familiar with their clinical policy bulletin on weight loss surgery and build your appeal based on that.

I was told I may not qualify by my surgeon, but I researched and provided my own argument with my submission and was approved on my first attempt. I also worked at Aetna for many years and was familiar with their process.

Here is an excerpt from the bulletin, this is what I would start with.

http://www.aetna.com/cpb/medical/data/100_199/0157.html

[newme37 16]

I forgot to add the part pulled from bulletin :/

Member has attempted weight loss in the past without successful long-term weight reduction; and

Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multi-disciplinary surgical preparatory regimen):

[Mandylove 32]

Thank you all so much!!! I will look into all of that. I'm really hoping it comes back overturned. I had done so much in hopes of approval the first time around. I made the mistake of sending in my Jenny Craig records as my 6 months diet where I had lost weight. Thank you again! Hoping to hear something soon.

[newme37 16]

Just keep appealing and look for the loop holes !

There are always loop holes, feel free to MSG me and I'll help you in anyway I can

[Sojourner 2,446]

Hi all,

I was recently denied by Aetna for lapband due to not having a high enough weight for 2 years. My problem was that I lost some weight on a supervised diet (Jenny Craig) and then gained it all right back, so the insurance company denied me for having once lost weight. I have now developed a thyroid problem which makes it that much harder to loose weight. In saying all this, I am working with lindstrom advocacy to hopefully get it over turned. Has anyone worked with them having Aetna and had success. I'm very discouraged and want this really bad! Any information would be greatly appreciated

-Mandy

I was required to submit 3 years worth of medical records to Aetna with other current documentation regarding the 6 month supervised diet and letter of medical necessity.

The surgeon's office was not very optimistic with my being approved, as there were significant breaks in the time that my weight had been recorded. I was advised to submit a letter to the surgeon's office to explain why so many weight records were missing (scale was located in an area where HIPPA regulations could not be adhered to), and my PCP included in his letter of medical necessity that I had been obese for the entire time he had been my physician (9 years).

I was approved with the first letter...Best wishes to get through the appeal process...

[cunner 21]

Mandy,

My story is very much like yours. Here is a post i made almost 2 years ago now. Please stay with it. Kelley and Walter Lindstrom are so helpful. I am 21 months post surgery now and slightly below my goal weight. Search for my posts to see my frustrations while going through the approval process. I picked this one as it made me very happy

Posted August 4, 2011 - 3:10 PM

Congratulations to everyone that was approved.

I have Aetna and was denied. the denial was upheld in the first and second level appeal by Aetna. It was so stressful.

The final appeal is an independent external review process. This is where the decision goes out to an independent doctor not associated with the insurance company who will decide based upon the information provided if the patient meets the standards published by NIH and other medical groups. Mine did and the decision by Aetna was overturned. The entire process took almost 10 months and was SO stressful.

All of my appeals were done with the help of

http://www.obesitylaw.com

It cost me nothing and Kelley is the BEST !! She called me 2 days before I was going to Disney to tell me the good news. She even offered to give me passes to Disneyland that they use to take out the employees in the office each year. Unfortunately I was going to Disney World in FL so I couldn't use the passes. She was so nice I decided I would tell everyone who was having issues with approval about them. They provide an awesome service to people who could really use help. I believe her husband Walter had both Gastric bypass and a Lapband revision later on.

Good Luck to anyone having to deal with Aetna.

1st Lap band seminar: 12/14/2009

Highest weight: 253

Pre-op diet starting weight: 247

Banded: 12/28/2010 : 236

1st fill: 2/8/11 (4.5cc)

2nd fill: 3/15/11 (7cc total)

3rd fill: 4/25/11 (8cc total)

4th fill: 9/30/11 (8.5cc total)

18 months post-op: 175

[jarchuleta 20]

Mandy' date='

My story is very much like yours. Here is a post i made almost 2 years ago now. Please stay with it. Kelley and Walter Lindstrom are so helpful. I am 21 months post surgery now and slightly below my goal weight. Search for my posts to see my frustrations while going through the approval process. I picked this one as it made me very happy <img src='http://www.bariatricpal.com/public/style_emoticons/<#EMO_DIR#>/smile.png' class='bbc_emoticon' alt='' />

Posted August 4, 2011 - 3:10 PM

Congratulations to everyone that was approved.

I have Aetna and was denied. the denial was upheld in the first and second level appeal by Aetna. It was so stressful.

The final appeal is an independent external review process. This is where the decision goes out to an independent doctor not associated with the insurance company who will decide based upon the information provided if the patient meets the standards published by NIH and other medical groups. Mine did and the decision by Aetna was overturned. The entire process took almost 10 months and was SO stressful.

All of my appeals were done with the help of http://www.obesitylaw.com

It cost me nothing and Kelley is the BEST !! She called me 2 days before I was going to Disney to tell me the good news. She even offered to give me passes to Disneyland that they use to take out the employees in the office each year. Unfortunately I was going to Disney World in FL so I couldn't use the passes. She was so nice I decided I would tell everyone who was having issues with approval about them. They provide an awesome service to people who could really use help. I believe her husband Walter had both Gastric bypass and a Lapband revision later on.

Good Luck to anyone having to deal with Aetna.

1st Lap band seminar: 12/14/2009

Highest weight: 253

Pre-op diet starting weight: 247

Banded: 12/28/2010 : 236

1st fill: 2/8/11 (4.5cc)

2nd fill: 3/15/11 (7cc total)

3rd fill: 4/25/11 (8cc total)

4th fill: 9/30/11 (8.5cc total)

18 months post-op: 175

Great story. I was banded on the 12 th. Aetna is my srcondary and I am in first appeal. I just paid the secondary and will see. Thanks to all for he good resources.