Denial after Precertification Approval (Aetna)?

[NewBeginning2015 46]

Hello there, my surgery is tomorrow (New Years eve!) and I have been up all night worried that my insurance approval will be overturned because I have gained weight since the approval several weeks ago. The approval letter states "The information provided above is not a guarantee of coverage. Coverage is based on all the terms and conditions of your plan as well as eligibility at the time services are received."

My Aetna plan requires a 90 day pre-surgery regimen, and states: "Records must document compliance with the program; the member must not have a net gain in weight during the program."

I lost weight during the program, but gained 4 pounds after the approval letter was received. Does anyone know if Aetna ever denies paying for surgery after pre-approving? Am I over thinking this? :-s

[wannaBthinsoon 1,634]

Just my thoughts, but 4 pounds isn't a "net gain". I personally think you may be worrying over nothing. Stress or too much salt in holiday foods could hold 4 pounds of Water on you. I seriously doubt you ate an additional 3500 calories (times 4) to gain the 4 pounds. I doubt anyone will ever even comment about it at the hospital.

[LipstickLady 25,682]

I didn't have to get on the scale the day of surgery. Relax.

Good luck! You're going to be fine.

[NewBeginning2015 46]

Thanks much, WannaBeThinSoon and LipStickLady! I feel much, much better. It's good to put it into perspective, and even better to know that I may not even be weighed when I go in for surgery! :-D

I think I am just a bit unsettled and worried in general...you know, how will I handle the surgery, etc. I need to be thinking positively about the good changes that are on the horizon.

PS., love the signature, LipStickLady. It gave me a good laugh.

[Elode 8,093]

@@NewBeginning2015 I would be completely amazed if you got denied the day or surgery...not going to happen! I was not even weighed the day of surgery. Don't worry about it , it's a little to late your surgery would be done before they ever knew anyway!

[Jersrose43 837]

As an insurance professional the reason that clause appears in your approval is because they can't guarantee that you will have coverage

You have approval but your employer may cancel and switch coverage. If it's a personal plan you may not pay the premium. If it's cobra you may not pay the premium. If it's employer plan you may quit or get fired between approval and surgery.

Basically they put that clause in so that if something happens to your benefit they're not responsible to pay it because an auth exists.

You're concerned for no reason.

[NewBeginning2015 46]

As an insurance professional the reason that clause appears in your approval is because they can't guarantee that you will have coverage

You have approval but your employer may cancel and switch coverage. If it's a personal plan you may not pay the premium. If it's cobra you may not pay the premium. If it's employer plan you may quit or get fired between approval and surgery.

Basically they put that clause in so that if something happens to your benefit they're not responsible to pay it because an auth exists.

You're concerned for no reason.

Ah that makes so much sense! Thanks so much for explaining. I'm chilling out now! Just enjoying the last evening with my hubby before surgery tomorrow at 7:30 am! :-D

[majorsmama 91]

Hi! I have Aetna too so can I ask a couple of questions???

1) How long did your approval process take?

2) Was Aetna easy for you and/or your surgeons office to work with? Were there any hiccups along the way?

3) How long from the end of your 90-day program/diet until your surgery date?

4) Did Aetna require anything other than the 90-day diet? Did they make you submit to a psych eval?

Thanks and GOOD LUCK!

[Jersrose43 837]

One thing that's critical to know about aetna is that once you start you cannot gain any weight. I mean zero! If you gain weight during the process you will be denied and will have to start over

[NewBeginning2015 46]

Hi! I have Aetna too so can I ask a couple of questions???

1) How long did your approval process take?

2) Was Aetna easy for you and/or your surgeons office to work with? Were there any hiccups along the way?

3) How long from the end of your 90-day program/diet until your surgery date?

4) Did Aetna require anything other than the 90-day diet? Did they make you submit to a psych eval?

Thanks and GOOD LUCK!

Hi there Majorsmama,

I was told by the surgeon's office that they find Aetna the easiest to deal with, and very responsive. Personally I found Aetna a bit frustrating, especially when I called. I would get different info from different reps. I later discovered that i got better answers when I used Aetna's secure email feature. Hopefully that will help for you.

1. I was approved in 13 days.

2. It was pretty straightforward to deal with them. But I understand that Aetna plans can be different so called, and it was difficult to get info about what they covered up front.

3. I had surgery 2 weeks after the last day of my 90-day supervised program. I was trying to get it in before the end of the year, so my surgeon's office helped by booking me immediately when we got the approval -- which meant surgery on new years eve. :-D

4. The 90 day diet I was a part of had a psych eval and regular PT and nutritionist appointments.

I did actually gain weight during the 90 day program, but it did not disqualify me because they said they only counted weight at the start of the 90 days and weight upon day of submission for approval (at the end of the 90 days).

Hope that helps! Let me know if you have more questions.

[majorsmama 91]

How are you feeling after surgery? How has the recovery been?

[NewBeginning2015 46]

Hi @@majorsmama, post op has been worse and better than I imagined. The pain of the incisions isn't the worst thing, for me. The worst thing has been the adjustment to the new size stomach -- pain upon drinking too much, belching, heartburn, grinding up pills because I cant take them whole, etc. It is just way more uncomfortable than I anticipated. But I am only in day four, and already am seeing a positive change in adapting to the new stomach, so I think/hope that this may pass soon. The scales are certainly making me happy! :-p

[CountryGirl5584 115]

I also deal with insurances all day. I work in a gastroenterologist office and we do colonoscopies and gastroscopies all day. I check the benefits allllll day long lol and hear this little stipulation every time I'm on the phone with the insurance company. They say this pretty much to cover their behinds incase you get discharged from your job or you quit. @Jersrose43 is 110% correct in the way she has explained it!!

[NewBeginning2015 46]

I also deal with insurances all day. I work in a gastroenterologist office and we do colonoscopies and gastroscopies all day. I check the benefits allllll day long lol and hear this little stipulation every time I'm on the phone with the insurance company. They say this pretty much to cover their behinds incase you get discharged from your job or you quit. @Jersrose43 is 110% correct in the way she has explained it!!

Thanks @@CountryGirl5584! That is reassuring to have it confirmed. I've yet to see a bill from Aetna (had my surgery on 31st Dec) so am waiting to wee wha it ends up being. :-D

[beautiful12no 42]

I had my first appointment with surgeon in Virginia on October 15. I weighed 265. I had my first appointment with my primary care on October 31 I weighed 269. I had my second appointment with my primary care on November 18. I weighed 276.2. I had a third appointment with my primary care and I weighed 276.4. Worried about net weight gain, I did the cabbage Soup diet and went back to my primary care on January 6. I weighed 266.2. My surgeon submitted my paperwork to Aetna open access on January 9. The surgeon was told I was denied due to net weight gain. Unknown to me the surgeon coordinator appealed on my behalf indicating blood pressure medicine had caused me to gain Water weight and that I had since been on a diuretic and lost weight. Aetna approved on Friday, January 16. Submittal rejection appeal and approval all took 7 days. My surgery is scheduled for February 12.