Aetna

[Kerra 4]

I am gutted

I had my surgery back in April, and couldn't be happier. In fact, my husband is scheduled for surgery on Monday 7/30.

Well, anyways, the center KNEW from the beginning that he did not have a 2 yr weight history, which is required by Aetna. They told him that they have ways around that one and not to worry. Got a denial letter two weeks back and was told "don't worry- surgeon will do a peer review and they very rarely deny them." this was all from the insurance coordinator at the center.

He went in to sign preop forms today. He asked the surgeon if it was taken care of. He was shocked to hear this- said he was not notified by said insurance lady, and that he would have a word with her and get it done today.

Well, afternoon rolls around and he gets a call from the insurance lady from the center. Peer review was a fail and she told him to start getting his weight documented and to come back and see them in two years!!!!! I am absolutely disgusted with how unprofessional she had been throughout his whole process.

We are out about $1200 from co pays, deductibles, co insurance, time off from work, etc for him to be a part of the program. I am beyond pissed off- his leave was already submitted for work, etc. Who does the insurance coordinator think she is? Lying and then forgetting to mention to the surgeon of the issues?

My question for you guys- anyone ever been denied from Aetna for not having a clinically documented weight history, proving obesity for two years? They will not accept his records from 2007&2008. Wondering if there truly is a way around it like we were told in the beginning? If so, what did you do?

We have submitted an appeal directly with the insurance company as we feel we cannot be bothered with the insurance coordinator at the center any more. But that a) will take 30-45 days; will most likey be denied.

[michele39 7]

I h w Aetna and they did require a 2 yr weight documentation but that can consist of any weight documenting has he been to any doctor at all in the last 2 yrs that has recorded his weight?? Weight watchers? A journal anything at all???

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[Kerra 4]

He has nothing. I did not encounter this with the same insurance as I had two years of documentation. We knew it was required, so ot was the first thing he told them before signing onto the program. Her exact words were not to worry about it, there are ways around it. Now he is being told to come back in two years by the same lady? Unacceptable.

[7Grijalva7 1]

He has nothing. I did not encounter this with the same insurance as I had two years of documentation. We knew it was required' date=' so ot was the first thing he told them before signing onto the program. Her exact words were not to worry about it, there are ways around it. Now he is being told to come back in two years by the same lady? Unacceptable.[/quote']

Sorry to hear about that. That has to hurt! Hopefully there r ways around it. If ur spouse has seen a dic prior and mentioned anything about his weight maybe u can submit that paper work and say that's when it all started.

[Kerra 4]

I was just thinking- he did belong to weight watchers at one point- probably 2009/2010. Anyone know how he could get those records? I don't think he saved anything, unfortunately. I am more than gutted. He was not only psyched about getting the band, but also about getting his hiatal hernia fixed to help his GERD.

[Sojourner 2,446]

I had my surgery approved through Aetna, and there were long stretches during the required 3 years of medical documentation where there was no weight recorded for me.

What is his BMI, and what, if any comorbidities does he have? These numbers figure substantially with insurance companies and the decisions they make.

I was asked to write a letter to Aetna to explain why there were substantial gaps in my weight records, which I did, and did not have any problems with having my insurance approve my request for surgery with the first request.

What also helped was that in his letter of medical necessity, my PCP did include the length of time he had been my doctor, that I had been obese for the entire time he had been my doctor (9 years), past failed attempts to achieve permanent weight loss, and listed my weight related comorbidities (I have 4, BMI at time of approval was 38).

This is one reason why it is vital to have a professional relationship with a physician. They can substantiate your medical history, and help with filling in any "gaps".

Don't give up...but begin the process to provide the required medical documentation while you request Aetna to reconsider their decision.

Good luck...

[Bubie1916 59]

I am gutted

I had my surgery back in April, and couldn't be happier. In fact, my husband is scheduled for surgery on Monday 7/30.

Well, anyways, the center KNEW from the beginning that he did not have a 2 yr weight history, which is required by Aetna. They told him that they have ways around that one and not to worry. Got a denial letter two weeks back and was told "don't worry- surgeon will do a peer review and they very rarely deny them." this was all from the insurance coordinator at the center. I was denied for the same reason and I'm trying to work on an appeal, don't know what will happen. It sucks!

He went in to sign preop forms today. He asked the surgeon if it was taken care of. He was shocked to hear this- said he was not notified by said insurance lady, and that he would have a word with her and get it done today.

Well, afternoon rolls around and he gets a call from the insurance lady from the center. Peer review was a fail and she told him to start getting his weight documented and to come back and see them in two years!!!!! I am absolutely disgusted with how unprofessional she had been throughout his whole process.

We are out about $1200 from co pays, deductibles, co insurance, time off from work, etc for him to be a part of the program. I am beyond pissed off- his leave was already submitted for work, etc. Who does the insurance coordinator think she is? Lying and then forgetting to mention to the surgeon of the issues?

My question for you guys- anyone ever been denied from Aetna for not having a clinically documented weight history, proving obesity for two years? They will not accept his records from 2007&2008. Wondering if there truly is a way around it like we were told in the beginning? If so, what did you do?

We have submitted an appeal directly with the insurance company as we feel we cannot be bothered with the insurance coordinator at the center any more. But that a) will take 30-45 days; will most likey be denied.

[Bubie1916 59]

I was denied for the same reason, I'm working on an appeal now. I'm hoping it will work for me and you. It sucks!

[sandra07 17]

I has surgery with Aetna and all I need was to list all the diets and whatever else I had done to loose weight and for how long I did it and how many pounds I lost and gained back and a letter from my primary doctor saying the same thing and her recommendation for me to having the surgery done!

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[Kerra 4]

Sandra07- when did you have surgery? Apparently Aetna updated their requirements this year.... Not sure when. We are still getting nowhere. Depressing.

[Kerra 4]

Sojourner- BMI is 40; no comorbities. He is rather healthy and has not see a doctor for years because of that. Wished he had at least gone for physicals every now and again.

So today, I have set him up with a PCP that he will see tomorrow, hoping that she can write a letter. I also contacted his pediatrician to get his weight

history from childhood and adolescence. Lastly, I was able to obtain his weigh ins from Slimming World (much like weight watchers) but they are unofficial so I am not sure they will do much of anything. But I thought I would include them along with the appeal.

Hoping with all I have that this works.

[sandra07 17]

June 20, bmi 44 no comorbities. After everything was submitted I got approved in less the 2 hrs! Before my primary doctor did my letter she asked me all the diets I have done so she can write it on the letter because I only been seen her for 1 year or so!

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[Kerra 4]

Thanks Sandra! You have given me a glimpse of hope that we my win this appeal!!

[Dawn200321 146]

I have aetna. They wanted 3 years weight history from me. I was missing one year and was told by the ins coordinator to write a letter to aetna. I did as instructed and was approved the first time.

[cunner 21]

This is so much my story. I have Aetna. Was denied, appealed, denied again.

I was so depressed about it after all the months of preparation. At one point I was 36 hours from surgery when my 1st denial came. It sucked so bad to get those letters I still hate to think about it.

After researching here someone suggested Lindstrom Obesity Advocacy.

The web site is: http://wlsappeals.com/

Kelley did my appeals and she was awesome. Basically we went through every appeal with Aetna and got a denial at every level. I was devastated but she assured me it was OK and within the plan of action. After exhausting all Aetna appeals it goes to independent external review. My denial was overturned and after and entire year of appeals I finally got my surgery.

The date was Dec 28, 2010. I have now lost just about 85 pounds. My Nurse Practitioner asked me to attend the introduction seminars they have at the hospital to speak with new patients even.

The cost for the entire appeal process which was handled entirely by Kelley at Lindstrom Obesity Law was exactly $0. She was so so good I want to be sure anyone with approval problems knows about this service that Kelley and Walter Lindstrom provide. They really are awesome. Call them and see if they can help. I will be glad to answer anything else here or in a PM if you like. This is the best thing I have ever done for myself and family. I plan on living a long time to see my kids grow up.

BTW: Aetna Sux !! Good Luck to your husband.