Approval Anxiety is Getting to Me

[Neoteric Verve 65]

The whole process gets me more and more anxious the closer I get to being able to submit for approval. I've combed my insurance (Aetna) clinical policy bulletin backwards and forwards. A little history:

BMI is over 50 dating back over 7 years it has gone from 43 up to nearly 54 (53.1)

My PCP has for the past 3 years advised me on weight loss methods

I have had my psych evaluation and clearance

Attended a nutritional counseling and a support group

Labs and ECG (EKG) are done

Now I'm not sure how, but my surgeon's office said I was eligible to submit under Aetna's "Physician-supervised nutrition and exercise program". I have had monthly visits to my PCP regarding my weight and remedies for the last several years. The surgeon's office manager was apparently overwhelmed when my PCP sent over seven years of charting. So, my question is do I allow the office to submit now or wait until after the second week of August after the 3-month program of the surgeon is completed?

[AutumnBlueCarmen 4]

Waiting is so hard! I don't have any input on when to submit insurance....sorry. My gut says wait, but others might have more insight. Sending you happy healthy vibes and patience (just a little...I don't have much to spare ;P ) . One day at a time! ((hugs))

[Khy 16]

How many apointments with the Nut have you had? My Dr. filed early. They say they want 3 visits with the nut but what they really want is 4. My insurance is aetna also. Go back and read my topic labeled Advocate for Yourself. Aetna is very busy this time of year. The only reason I got my approval when I did ( and it was not fast) was because I kept calling and asking. You need to get them to put you in the system and you need to make sure all your paperwork is attached to your file.

Khy

[Neoteric Verve 65]

Thanks ladies. Khy, that's my issue. I have only been to one NUT counseling and a support group. I read the bulletin (0157) and it appears that I qualify under section I-C-1:

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Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record at each visit. This physician-supervised nutrition and exercise program must meet all of the following criteria:

1. Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation (GOT THIS DONE). The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records; and
2. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dietitians and/or nutritionists, with a substantial face-to-face component (GOT THIS DONE); and
3. Nutrition and exercise program(s) must be for a cumulative total of 6 months (180 days) or longer in duration and occur within 2 years prior to surgery (GOT THIS DONE), with participation in one program of at least three consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.)

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[Khy 16]

Well it seems you have it done. Get that last Nut in and then I would have them submit asap. Under 1-C-1, did you work with a nutritionist during that part? If so... then you should be able to submit now. I quaified under the 3 month physician and nut presurgical program. The insurance coordinator at my Dr. office is pretty insurance savy. We kinda worked as a team. I would call and find out what was needed and then I would call her and she would get it in that day. The longest part was getting them to put me in the system. I would call and they would say they recieved it but I wasn't in the system yet. Your paper work won't go to the nurse for preview until somebody takes the time to enter you into the system. After a few days I would start expressing concern that you are not in the system when you call them. That prompts them to transfer you to someone else and they will put you in the system. Once the nurse gets it, she will say if any other documentation is needed. Sometimes they will tell you what is needed and other times not. It depends on who answers the phone. I did have a couple of people say that something was needed but wouldn't tell me what. Others were up front and told me what the insurance coordinator needed to send. Then you have to prompt them to attach anything extra that was sent to your file. After that you will be approved or denied shortly. Sounds like you meet the qualifications so I would think they would approve you.

Khy

[ITSMEMRSJ 3]

Hi,

I'm so anxious and nervous too!

I have Aetna Choice Plus and completed all the requirements (3 NUT appt, PCP Let, Psych/Cardiac/Pulmonary/End clearance) on 7/5/11. My surgeon's office is handling everything I don't even know when my info was submitted. My clinical coordinator says they usually have no problems with Aetna, they call them with the approval. I have a surgery date already, but I'm so nervous, like its not really real since I have not heard a formal approval or received a letter from Aetna. I don't want to call Aetna because if I was to here that I wasn't approved I would be devastated

[cindy lynn 0]

I have Aetna also, although the policies due differ depending on your employer. My surgeon gave me specific forms for each different qualifier to complete (primary physician, psychologist, nutritionist). So after the 4 months needed for my policies qualifications, I faxed my surgeon the paperwork and they wrote a letter to the insurance company and filed the paperwork. I was approved in about 10 days

Maybe all the paperwork from your primary is too much and needs to be simplified. Good luck - keep us posted

[Khy 16]

Aetna is very busy at this time of year. You might want to read my topic Advocate for yourself. If you jump through all their hoops they are pretty good about approving but they are pretty exacting about the hoops.

Khy