Denied!????

[Chylyn7 26]

Ok so my insurance denied me because my BMI was only over 40 for 3/5 years! How can I appeal this??? My plan states that it must be over 40 for 5 years in a row.

[BLERDgirl 6,417]

Talk to your bariatric team. Usually they have a medical coordinator who can work with you on appeal. Additionally if you have any other health issues that are impacted due to excess weight, have that thoroughly documented.

[acyum2008 55]

Well what insurance do you have? I have Aetna and they want only 2 years. There has to be a loop hole.

Here is what they require if you have Aetna.

Must meet either 1 (adults) or 2 (adolescents):

1. For adults aged 18 years or older, presence of persistent severe obesity, documented in contemporaneous clinical records, defined as any of the following:

   1. Body mass index (BMI) (see appendix) exceeding 40; or

   2. BMI greater than 35 in conjunction with any of the following severe co-morbidities:

      1. Clinically significant obstructive sleep apnea (i.e., person meets the criteria for treatment of obstructive sleep apnea set forth in CPB 0004 - Obstructive Sleep Apnea in Adults); or
      2. Coronary heart disease, with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure or prior myocardial infarction); or
      3. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes); or
      4. Type 2 diabetes mellitus
         

[acyum2008 55]

Well what insurance do you have? I have Aetna and they want only 2 years. There has to be a loop hole.

Here is what they require if you have Aetna.

Must meet either 1 (adults) or 2 (adolescents):

1. For adults aged 18 years or older, presence of persistent severe obesity, documented in contemporaneous clinical records, defined as any of the following:

   1. Body mass index (BMI) (see appendix) exceeding 40; or

   2. BMI greater than 35 in conjunction with any of the following severe co-morbidities:

      1. Clinically significant obstructive sleep apnea (i.e., person meets the criteria for treatment of obstructive sleep apnea set forth in CPB 0004 - Obstructive Sleep Apnea in Adults); or
      2. Coronary heart disease, with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure or prior myocardial infarction); or
      3. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes); or
      4. Type 2 diabetes mellitus
         

[Chylyn7 26]

Well what insurance do you have? I have Aetna and they want only 2 years. There has to be a loop hole.

Here is what they require if you have Aetna.

Must meet either 1 (adults) or 2 (adolescents):

• For adults aged 18 years or older, presence of persistent severe obesity, documented in contemporaneous clinical records, defined as any of the following:

• Body mass index (BMI) (see appendix) exceeding 40; or

• BMI greater than 35 in conjunction with any of the following severe co-morbidities:

• Clinically significant obstructive sleep apnea (i.e., person meets the criteria for treatment of obstructive sleep apnea set forth in CPB 0004 - Obstructive Sleep Apnea in Adults); or
• Coronary heart disease, with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure or prior myocardial infarction); or
• Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes); or
• Type 2 diabetes mellitus

I have United Healthcare... My dr is suppose to do a peer to peer with the insurance company

[acyum2008 55]

Any word from your insurance company? @@Chylyn7

Any word from your insurance company? @@Chylyn7

[Chylyn7 26]

Any word from your insurance company? @@Chylyn7

Any word from your insurance company? @@Chylyn7

My dr office missed the phone call for the peer to peer review last Friday. So it's rescheduled for 9/25... I've been in contact with HR they said if they deny me again to contact them. My company is self funded so they will most likely approve my surgery