I Need Help Getting Approved For Gastric Sleeve Surgery

[omamilam 11]

Hi,

I'm just starting the supervised thing. I went to my PCP doctor today and told him what the insurance company expects in order for the procedure to be covered by Aetna. He replied that he had never had to do that criteria before and the insurance companies know they are better off if you have the surgery so they don't get that technical. I told him I had just spoken an hour ago to the Bariatric Team coordinator and wrote down what I needed to do. He said the Bariatric office will do the 6 visits and I said they told me you would do them. All he told me was to cut down to 1500 calories a day and to exercise. The Bariatric team said the diet had to come from a nutritionist and exercise had to be documented. I am so confused right now.

Did anyone have problems like this? What happened? How do I get my doctor to comply? Who did your visits the PCP or the Surgeon? I am so frustrated!

Vicki (Oma Milam)

[IslandGrrl 11]

I had some problems in the early months. Although my GP was supportive, they weren't 100% sure about exactly what the insurance company expected to see. I lost about 3 months, because I was going to the nutritionist and weighing, but no one was capturing all the "right" information in one place. One day, I called the insurance company and spoke with someone who handles the bariatric program. (I can't recall the exact job title.) She told me that medical group (insurance) had a form that captures all the information they need, and that they would send the form to the doctor. At my next visit, the doctor began using the form. I continued to see the NUT for the six months, but I also had a monthly weigh in at the GPs office where I answered questions about my exerceise and some other health behaviors. At the end of the 6 months, both the NUT and the GP submitted their information along with the other requirements. I think having the form made it fast and easy for the GP, and as a result their office seemed to be much more willing to keep the necessary records.

[omamilam 11]

Thanks, Island Girl, I will see if my insurance company has a form also. I don't want to lose time but it is probably inevitable.

[Less of Leslie 90]

I don't know if you have an *** or PPO. If ***, DEMAND that your pcp refer you to the bariatric specialist you chose and have the specialist jump thru the hoops for you. They know more about it than your PCP does. If PPO, self refer!!!

[BenisaMartim4 369]

My pcp was confused about what he was supposed to do too. I'm still not sure we did it right. I am still waiting on my approval. It was submitted on the 26th of last month and is still out. I have already lost my surgery date because they are taking so long. If it needs more work, hopefully we can get it all in this time. I have rescheduled for Feb. 14th, 2012.

[illgeturhairdid 176]

I am doing the three month program required by Aetna. If you go to Aetna's website they have what they refer to as a Clinical Policy Bulletin, look for the one on weight loss surgery. Printing this and giving it to your doctor will probably help them a lot if they aren't familiar. My surgeons office has a wonderful program and I am working with their nutritionist and doctors and they have given me a very specific diet plan that is working well when I follow it the way I should! Good luck to you!

How did you get someone on the phone from Aetna?!? I got someone who was hard to understand and who just kept referring me back to the website. I would LOVE to speak with someone who coordinates benefits at the insurance company!

[TiffanyC 7]

I saw my PCP for the 3 month diet counseling required by BCBS, and I did not loose weight during that time either. I had lost 60 lbs on my own over a year ago and this was during a time of gaining all that lost weight back. So just FYI - I got approved even though I was gaining weight during that time.

[time2liveagain 2]

Post deleted by januarythomas

Edited November 30, 2011 by januarythomas