Help! Need tips on appeal process

Gigi001 · March 8, 2005

My insurer (Aetna) denied my claim for surgery - even though it IS covered under my group plan. So I need to mount an appeal. I'd appreciate hearing from anyone who has done an appeal that has been successful...what you had to do, did you need legal advice, etc.?

Thanks

G

Alexandra · March 8, 2005

Hi Gigi,

There are a lot of variables in an appeal. Why was coverage denied? Was it because you are not medically qualified? Or did Aetna fall back on the "investigational" gambit?

I was able to fight Aetna and eventually won because my state has a third-party appeal process. In my case Aetna was denying solely because they considered the band investigational, and that's the ruling that was overturned on appeal.

How you proceed depends on why you were denied. Your denial letter should have provided information on the next step you can take--which is probably just appealing within Aetna. Whether you need legal help also depends on why you were denied. So what did your denial letter say?

I'llsucceed · March 20, 2005

The only thing i could tell you is that my insurance said that I should have my surgeon write the appeal because it will go through the process faster than if I write it. So I am now waiting- I was denied at first.

magster · March 21, 2005

from my understanding Aetna has not approved this surgery and will never approve this surgery based on its experimental status- I also have aetna and was not willing to go through the heartache of doing all that tedious paperwork only to be denied- if you make some progress please let me know.

Alexandra · March 21, 2005

from my understanding Aetna has not approved this surgery and will never approve this surgery based on its experimental status- I also have aetna and was not willing to go through the heartache of doing all that tedious paperwork only to be denied- if you make some progress please let me know.

Magster, if Aetna is denying based on "experimental" status, it stands to reason that SOMEDAY that "experimental" status will no longer be viable. After a while, new procedures that work STOP being experimental.

But it's not true, in any event, that Aetna denies based on that reason alone. Aetna clearly shows a preference for RNY (though I really believe that will change after another year or so), but if you can provide medical reasons why RNY is not right for you they WILL approve the band. Look at their website (under Coverage Policy Determinations--Obesity Surgery) for specific reasons why banding would be approved over bypass.