I have been denied by Aetna for VSG. First because they stated I didn't meet the criteria of weightloss. However, I appealed and proved that I do meed the medical criteria however, they came back with a second denial because they say that I didn't meet psych clearance. Which was untrue. I faxed in the pysch clearance but now they want to do a Level II appeal committee tele - conference. I can choose to phone in and state my case to an unknown board I will be given 15 minutes to do this. Then I will be asked to leave the call where they will deliberate without me and send me a letter with their decision within 5 business days. They also state that I can have a lawyer present it I want to. WTF. Does anybody have any experience with this? What should I expect?

I have been denied by Aetna for VSG. First because they stated I didn't meet the criteria of weightloss. However, I appealed and proved that I do meed the medical criteria however, they came back with a second denial because they say that I didn't meet psych clearance. Which was untrue. I faxed in the pysch clearance but now they want to do a Level II appeal committee tele - conference. I can choose to phone in and state my case to an unknown board I will be given 15 minutes to do this. Then I will be asked to leave the call where they will deliberate without me and send me a letter with their decision within 5 business days. They also state that I can have a lawyer present it I want to. WTF. Does anybody have any experience with this? What should I expect?

OMG that scares me!! I have Aetna! I am now awaiting their decision. My Dr. told me that he thought they would approve me ( and on my plan they only pay half...) . the more I read about Aetna the more I think they are dedicated to not paying. Can you afford the lawyer? This just might be their last ditch effort to not pay. Anytime lawyers are mentioned... people get scared. If you can, call their bluff! Let's see what happens when the lawyer is in on the conference call.

Khy

For us with Aetna (myself included), going through the pre-op phase hearing these stories is quite unnerving. They do in fact seem hell-bent on not paying. Well isn't this WHY we have insurance? I'm not willing to sacrifice my health any further just so some pompous corporate executive can have an extra $10k tacked onto his/her salary!!

Screw 'em. FIGHT. Bullies hate being hit in the mouth!!

I can't afford a lawyer nor do I know one that would be willing to speak on my behalf. I was a little intimidated and still is as a matter of fact, however I feel like I am fighting for my life and I will go in and with everthing I have in me. I believe in my father and he said ask and you shall receive. I know this surgery is the right thing for me and I have met all of their requirments so I am believing that I will prevail. Aetna has given me the run around since I submitted my paperwork. I am usually not a fighter but I feel so strongly that this surgery is right for me and it is what I need to get my health back so I am going to fight until the end.

Would your Dr. be willing to sit in on this conference with you? He would not be doing the surgery if he didn't think you needed it. I am just trying to think of a way to get you more power when you talk to the insurance company. Get all your documentation lined up. Anything you haven't checked out? Any possible co-moribdities? Line up your guns before you talk to them.

Khy

I hadn't thought of asking my Dr. especially since this particular office don't help with appeals. However its worth a try to call and see.

Would your Dr. be willing to sit in on this conference with you? He would not be doing the surgery if he didn't think you needed it. I am just trying to think of a way to get you more power when you talk to the insurance company. Get all your documentation lined up. Anything you haven't checked out? Any possible co-moribdities? Line up your guns before you talk to them.

Khy

i have aetna and they approved me the first time around but i had given my psych eval to my surgeon and they faxed it into aetna, i would call and refax your psych eval approval and then they should have no reason to deny u. but aetna will deny u if ur bmi is 35-45 if u dont have a co-morbidity also such as diabetes sleep apnea etc, so i would mmake sure you have that info ready as well.

Samantha,

I already re-faxed the psych eval. I also have a current bmi of 40. I have diabetes, high blood pressure,PCOS, high blood pressure and infertility. So I meet the requirements. I just feel like I am being given the run around. I called and asked why I still have to go before the committee when you have the information, hell they had the information from the beginning. They still advise I have to go through the appeal. Its just frustrating.