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Peer To Peer Review

Jbright

By Jbright, in Insurance & Financing

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Jbright    10

Jbright
Posted

Hi Everyone

I found out today I was denied by Aetna for not having a BMI over 40 for the last two years. Well, the reason for my BMI not being over 40 is because I have been going to weight loss doctors and be issued phentermine. My BMI has never been below 37 (well at least in the last 8 years it hasnt) Needless to say, Aetna stated my surgeon can complete a peer-to-peer review with their medical director. Has anyone else (preferrably w/Aetna insurance) had this happen? IF so what was the end result?

Thanks

Jbright

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MiniMi    1,468

MiniMi
Posted

You need to get tested for sleep apnea. If you have low bmi BUT have sleep apnea ( even a mild form) then they will approve it. That is the route I had to go. Pain in the butt, yes, but I was banded last Friday!

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twinkee    2

twinkee
Posted

My bmi is kinda low because of the same reason i have been on phentermine for weight lose .... When I went to my first consultation they said if I lose one more pound they won't approve I got frustrated... So haven't took my pills. In a week and now I'm made cause I gain 4 pounds:( so what am I suppose to do? Not take the pill for how ever long and gain weight? That would be crazy...

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Jbright    10

Jbright
Posted

You need to get tested for sleep apnea. If you have low bmi BUT have sleep apnea ( even a mild form) then they will approve it. That is the route I had to go. Pain in the butt, yes, but I was banded last Friday!

BandingMI, congratulations on your banding... I wish you much success!! I was tested for sleep apnea and was issued a CPAP machine. For some reason I thought the sleep apnea diagnose's was sent in with my case. Nonetheless, I found out today that my file was submitted that I was tested for sleep apnea. After speaking with the pre-cert department at Aetna the communication of me having to sleep with the CPAP machine as well as they didn't have my diagnoses which is 327.23. I will be calling my insurance coordinator (at the surgeon's office) first thing in the morning to ensure ALL of my information is submitted. Also, since the peer to peer hasnt been completed yet, I will also request my doctor mention the sleep apnea during the review.

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Jbright    10

Jbright
Posted

My bmi is kinda low because of the same reason i have been on phentermine for weight lose .... When I went to my first consultation they said if I lose one more pound they won't approve I got frustrated... So haven't took my pills. In a week and now I'm made cause I gain 4 pounds:( so what am I suppose to do? Not take the pill for how ever long and gain weight? That would be crazy...

HI twinkee, the pills does not do anything for me except keep me from gaining weight. I do not lose an ounce of weight when I take phentermine. Sounds like we are in the same boat. I stopped taking the pills in June and have gained 15lbs since June 2012. I am tired of taking pills as well. Good Luck with your banding!

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MiniMi    1,468

MiniMi
Posted

Job right, that's awesome! Less time needed. Unfortunately we have to be our own advocates at time. Go get 'me girl!

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MiniMi    1,468

MiniMi
Posted

Sorry jbright! iPad auto correct got your name wrong in my last post..gggrrr

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AnnLouise    7

AnnLouise
Posted

Hi everyone. I too was denied by Aetna. The specific policy on weight loss surgery is available on their website. I had to read it very carefully to see where my documentation was weak. It turns out that my comorbidities were not comorbid enough. Because my BMI was less than 40 and my hypertension was well controlled I got denied.

I provided strong letters from my medical doctor & my cardiologist to my surgeon. He then did a peer review with the Aetna medical director and changed his mind. Yipeeee! Going wednesday.

Sounds like with the sleep Apnea you might have a win. Good luck!

FYI my dr's office staff said they get up to 40% denials. WOW

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Jbright    10

Jbright
Posted

Congratulations, AnnLouise! I wish you much success! I am praying my surgery gets approved. Yes, reading Aetna's clinical bulletin was helpful to me as well.

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Jendkopp    62

Jendkopp
Posted

Jbright: did you get approved? I am in the exact same situation; while taking phentermine, my weight stayed at a 37 BMI. I'm no longer on phentermine and have a BMI over 44. Aetna denied, and now I'm waiting for the peer to peer review :(

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Jbright    10

Jbright
Posted

Jbright: did you get approved? I am in the exact same situation; while taking phentermine, my weight stayed at a 37 BMI. I'm no longer on phentermine and have a BMI over 44. Aetna denied, and now I'm waiting for the peer to peer review :(

Hi Jendkopp

Yes, my surgery was approved after the peer to peer review. I was diagnosed with sleep Apena and Aetna apparently did not consider the sleep apnea when the completed my first review. Do you have any co-morb?

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4thefuture31    20

4thefuture31
Posted

Hi Jendkopp

Yes' date=' my surgery was approved after the peer to peer review. I was diagnosed with sleep Apena and Aetna apparently did not consider the sleep apnea when the completed my first review. Do you have any co-morb?[/quote']

I was just diagnosed with moderate sleep apnea and bmi of 37. I hope Aetna will approve me!

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Jbright    10

Jbright
Posted

I was just diagnosed with moderate sleep apnea and bmi of 37. I hope Aetna will approve me!

Did you double check to make sure your insurance policy will allow obesity surgery treatment?

I believe the sleep apnea diagnoses should grant an approval(it did in my case). Keep fighting them (aetna) for approval! If they deny you I would contact "Lindstrom obesity advocacy" they may be able to help you and you may not have to pay anything out of pocket! I contacted them while waiting for the peer review to be completed just in case I wasn't approved.

Good Luck

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nicolemm    24

nicolemm
Posted

I have Cigna and my surgeon has a peer to peer review tomorrow. Cigna claimed I didn't complete my three month nutrition counseling, although I did, they did not read my clinical notes correctly.

I am SO nervous to be denied after the peer to peer review. My surgeon is confident it will be approved but the anxiety is driving me insane.

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AnnLouise    7

AnnLouise
Posted

After 2 peer reviews my surgeon finally got the Aetna director to budge. My comorbidities were borderline and BMI was 37. I was approved and banded on Oct 10. I recovered easily with time. About 4 weeks to full activity level. Anesthesia sucks! I have my 2nd fill tomorrow. I have very little restriction right now. Hoping to get out of "bandster hell" soon. Good luck. Press on!

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