Pending, denied, peer to peer and accepted!

[Tanglesia 15]

What a roller coaster of emotions this whole journey has been. All my records were given to insurance on July 3. Denied on July 15 for gaining on my 6 month of dr visits. My surgeon Dr Todd Eibes of Iowa Speciality Hospital did a peer to peer with my insurance Aetna today and he got it changed to ACCEPTED. start my pro op diet tomorrow and surgery on Aug 4th. Wow is all I have to say. Prayers answered!,

[dogloverlosingit 6]

Awesome! I just met with Eibes today and am switching over to him.

[fccm04 39]

Great doctor! Not to many will do that! Good luck!

[Westfield27 54]

This gives me hope. I also have Aetna and gained 7lbs. My paperwork was submitted to Aetna today but I was told I have a 90% chance of denial due to weight gain. What exactly is a peer to peer? I may need my doctor to do this.

[alwaysvegas 702]

This gives me hope. I also have Aetna and gained 7lbs. My paperwork was submitted to Aetna today but I was told I have a 90% chance of denial due to weight gain. What exactly is a peer to peer? I may need my doctor to do this.

In a peer-to-peer review, your surgeon and your PCP (if they will help also) will talk with the doctor from the insurance company to explain why you require the surgery even if you did not meet the insurance requirements and were denied.

The Aetna website (http://www.aetna.com/cpb/medical/data/100_199/0157.html) provides all the approval requirements and section C.1 describes the nutrition program and states, "...Records must document compliance with the program; the member must not have a net gain in weight during the program."

However, if you are denied, the reason(s) on which you were denied are provided in the denial letter from Aetna and will be discussed by your doctor(s) with Aetna. People have had great luck getting their denial overturned in the peer-to-peer. However, if you are denied again, you can request an external peer review, which is like an arbitration. Your doctors discuss your need for surgery with an "impartial" doctor outside of the Aetna who decides whether or not the surgery is medically necessary. The external doctor's decision is legally binding and Aetna has to agree with whatever the external doctor decides.