Aetna’s “Two Year History” Denial Overturned
Except in the “minds” of Aetna, there shouldn’t have been much controversy that this patient was a candidate for surgery. She was 5’4″ and weighed 276 lbs. – a BMI of 47.4. She had some serious comorbid conditions including GERD, degenerative joint disease in her weight-bearing joints, stress incontinence and she was showing signs of developing type 2 diabetes.
At the time her doctor submitted the preauthorization request for a RNY gastric bypass, this 43 year old female patient had already completed a supervised diet and received her nutritional, psychological and medical clearances . . . just like Aetna’s medical policy (0157) requires.
Easy approval, right? Not quite!
Undaunted by her immediate medical needs Aetna combed her chart and denied her surgery based on their determination she had not been morbidly obese for 2 consecutive years. Like virtually all of us suffering from this disease and constantly battling morbid obesity her entire life, she went on diets. Hell! Aetna “required” such a diet before allowing her to have this surgery. Her efforts were “successful” to the extent that she lowered her BMI, albeit temporarily, down to 38.8. Since Aetna uses such an overly restrictive definition of “morbid obesity” for members who have a BMI between 35 and 39.9, she now didn’t qualify for surgery under their medical policy despite her current BMI of nearly 48 – all because she lost some weight for all of a nano-second!
Unfair? Of course! Yet we see this all the time!
Being a very reasonable fellow, and figuring that this must all be a terrible clerical error, her surgeon participated in a “Peer to Peer” review with the Aetna Medical Director. He carefully explained the situation but not only did the Medical Director refuse to change the decision, he actually hung up on the surgeon during their telephone conference! Nice customer service, eh? Needless to say the patient was devastated and didn’t know what to do.
Referred to our office by her surgeon . . . . . . .
. . . . . she submitted our Patient Appeal Information Form, reviewed our proposal for services, decided to retain our office and we went to work. First came the chore of getting her medical records from a very large, somewhat uncooperative, health care system. Accomplishing that, we analyzed her case and filed an appeal.
After reviewing that first level appeal package, less than 30 days later, Aetna overturned their denial and approved her surgery. I’m happy to report she had her RNY Gastric Bypass on August 31, 2012 and is doing wonderfully. Don’t you just love happy endings?!?