Denied by Aetna HMO -Dr. Notes not good enough

kimmiev · September 4, 2006

Hello! This is my first post. I have been visiting this site for months in anticipation of having my lapband surgery.

Aetna HMO denied my predetermination because at my 6 months worth of diet supervision visits with my PCP, he only wrote that we discussed diet and exercise. They also wanted the wording "behavior modification" in the records. The funny thing is that my actual policy (employer)covers the lapband surgery. So, now I am undergoing the 3 month multi=disciplinary diet and nutrition program offered by my surgeon to see if Aetna will be happy with what they do. It's good, they have me meet with the nutritionist every visit, and give me lots of tools and tips to lose weight.

I guess my real question is- has anyone ever gotten approved by Aetna HMO in Texas (or anywhere) for the lapband? If so, what notes did you get? Any tips? I did the 6 mo of PCP supervised dieting, Psych eval, nutritionist visit, started exercising, and pretty much jumped through every hoop Aetna asked me to! My BMI is 52 and I have several co morbidities. I am starting to get discouraged and just want to give up. I am only 2 months away from maybe getting approved...

Any tips or help is totally appreciated!

Thanks!

Kim

bibytz · September 4, 2006

Hi,

Sorry for this set-back. I do not have the same insurance co. but encounter the same comment for the first refusal. I had the doctor re-do his letter. He made it like a table format and had columns for dates, diet prescribed (Atkins, WW, etc.), weight, comments. In conclusion he showed that I tried 3 different diets with some minimal weight loss and gaining back on the first 2 diets, and that served to proove that I could not succeed in any weight loss program without a WLS. It worked.

Good luck to you, keep fighting the insurance co. because if your surgery is not excluded, it is just a matter of formality and to give them all the necessary/right paperwork... like a government agency!

Ciao... for now.

JDru · September 5, 2006

I'm sorry to hear about your set back! I have Aetna too...I'm still waiting to hear if I'm approved yet. I did all the required criteria like you, but the one thing I am worried about is the doctor's notes. It sounds like they want something very specific. It's so frustrating!! Good luck with your 3 month program!!