My Aetna Select nightmare. Do I need a lawyer?

[msmalone 0]

:mad:Hi all. I don't know where to begin. The insurance is making this a very, very difficult journey for me. It has been full of red tape and misinformation. And I see no end to it in sight. The short version is that I'm 4'11 and weight 200lbs. I have had a documented over 35 bmi for the past 5 years. I have also had chronic high blood pressure / hypertension for the past 5 years. Also I was born with a congenital degenerative bone disease (Perthes Disease) that is affecting my hip and ankle. In fact, my left ankle is rubbing bone on bone when I walk. (very painful) So when I decided to go for the Lap Band System in February of this year, I contacted every doctor I had within the past 5 years. I collected all my records. I got a letter of recommendation from my PCP and my Orthopedic doctor. And then submitted all info to my Lap Band surgeon at the Cleveland Clinic in a nice organized, tabbed folder. I really tried to do my homework and be prepared. I went through all the pretesting. And my surgeon told me not to worry - that I am a perfect candidate. According to my Aetna policy I had to meet the criteria of 5 years of bmi greater than 35 with A severe medical condition like...hypertension. So I thought - this shouldn't be bad. I have met all their criteria. WRONG!

After my surgeon's staff submitted my initial request for approval, I was denied due to lack of supporting weight information from the past 5 years. When I contacted my surgeon's staff regarding this issue. I was told that they "LOST" my organized folder of medical records that I gave them. They could only submit my past 3 years of weight history and medical records they had via computer files. Therefore....I was denied. My surgeon's staff called me and said..."Don't worry....just fax the proof of weight for the missing years and you will be fine. The insurance company will overturn your denial." WRONG AGAIN! Yesterday was my last day to get a peer-to-peer meeting between Aetna and my surgeon to go over and correct the missing information. I had to call my surgeons office and inform them that is was the last day to appeal - as they had no clue. So Aetna had a peer-to-peer review yesterday will a fellow doctor ( not even my surgeon) and my appeal was denied. Aetna told me that it was denied because my case was "cosmetic surgery" and not medically necessary. ???!!!!!!??? I'm not even sure if my surgeons office forwarded the correct information to Aetna. I can't get any answers from anyone. My surgeon's office told me that they would look into it and get back with me, as the woman who was handling my case is out-of-town at a conference in San Diego. Aetna won't tell me anything! I am getting the run around from everyone. So I really feel like my case has fallen through the cracks. I don't know if I should seek legal help or not. Any and all advice appreicated. Sorry for the very long post. Thanks everyone!

Angry in Cleveland.

[Alexandra 55]

Msmalone, I totally feel your pain. Do you have an insurance broker who can help connect the dots? I do this all the time.

First, a denial for lack of information is not a denial of coverage and doesn't need to be "appealed." From what you say above, it seems there was only one actual denial and that's the one for "medical necessity." That one can be appealed, and you should proceed on that score.

In your denial letter you should have been given detailed instructions on how to appeal. You should get copies of everything that was submitted to Aetna, and be prepared to supply anything that is missing.

In your appeal letter, list all the material and information that has been submitted. Copy Aetna's criteria for medical qualifiations (I'm sure you have that documented somewhere) and show in your letter that you do, in fact, meet the criteria.

Aetna can't "not tell you anything." They MUST respond to your inquiries in a timely manner. You might want to contact Ohio's department of insurance (or health, whichever has jurisdiction over HMOs) and find out what the carrier's obligations are to you. Most states have a patient's bill of rights that guarantees you access to information. You should be able to find an advocate there, or at least information that can help you force Aetna to move it along.

Aetna is a behemoth but they have no interest in being sued. If you show that you are indeed medically qualified, and that you have met their criteria, and that your policy does not exclude bariatric surgery, they will cover you. Getting all those dots connected can be a challenge, but it's worth it in the end.