Denied

[Joymarie333 41]

I was denied because I didn't have documentation proving that I was in a three-month weight loss program with Dr. And nut. I have Aetna Ppo. I am having surgery through West medical for the Vsg. I did all my nutrition visit over the phone if I would have known that it had to be face-to-face and to get my weight for every visit. I would have done that but West medical did not inform me of this. My peer to peer has already taken place and they are requesting documentation of that I'm just hoping that was medical can get it together so that I can get approval out of this if not. Please give me your opinion what do you think my worst case scenario would be. Do you think I would have to do the three months over?

[ShrinkingPeach 1,291]

Unfortunately you have to be your own advocate. You need to know your insurance beforehand and follow their requirements to the letter. If your policy states you have to have the weigh-ins and do face to face then you will probably have to start over. Sorry to hear you have been spinning your wheels so to speak.

You can call your insurance and ask for a copy of the coverage for WLS and then you will know what is required if your surgery center doesn't.

Good luck!!

[cindyw41 761]

We have to do our homework. My surgeon told me to call my insurance several times and ask about my benefits.

But if your surgeon has preformed this surgery and has dealt with insurance companies, they have come across common criteria that the insurances require. They should've been at least somewhat informed and guided you in that direction.

The program that I am in requires 7 monthly meetings, a psychologist eval, 2 nut visits, food logs, tests

And monthly weigh ins. This is if your insurance requires it or not.

[Elode 8,093]

Worst case would be doing it over and if you do just keep positive and know it's worth it. It stinks I know but hopefully they will get it together and be done! Good luck!

[Joymarie333 41]

I had trust in them knowing the requirements I praying that whatever they faxed over today will get me approved if I have to another 3 months then I guess I have no choice thanks lady's for responding ????

[Sandra86says 92]

I had trust in them knowing the requirements I praying that whatever they faxed over today will get me approved if I have to another 3 months then I guess I have no choice thanks lady's for responding ????

Same thing happened to me last month. They called me to tell me I got denied because of the same reason... I was so pissed off. I have to do 6 months of weigh ins...so now I'm looking to get surgery January or February of next year... I'm not as bummed anymore because I understand this will benefit me in the long run with my eating habits. Good luck!!!

[Michelle Tarver 62]

I have Atean choice ll from my employer costco.

After the 1st group info session we were given the procedure codes and told to go look them up with our insurance company.

http://www.aetna.com/cpb/medical/data/100_199/0157.html

was pretty clear on what I needed to do.

Good luck to you! Maybe..if your surgeons office is not good with details dyou may want to look around at others in the area and see if they are? Or be very on guard for any more slip ups before surgery that set off alarm bells?

[Daisee68 2,493]

Mine was over the phone too but the NUT just had to send the documentation to the surgeon to get fined with the paperwork. I just had to tell him what my weight was that day.

[perfectlyimperfect44 46]

I had trust in them knowing the requirements I praying that whatever they faxed over today will get me approved if I have to another 3 months then I guess I have no choice thanks lady's for responding ????

Same thing happened to me last month. They called me to tell me I got denied because of the same reason... I was so pissed off. I have to do 6 months of weigh ins...so now I'm looking to get surgery January or February of next year... I'm not as bummed anymore because I understand this will benefit me in the long run with my eating habits. Good luck!!!

This same thing happened to me yesterday and i was sure the doctor office had all they needed and knew what was required before they sent the paperwork they were so sure I'd get approved they set me a tentative surgery date now im looking at January or February for surgery after I complete 6 months physician /nut supervised weightloss regemin

[Peanutbutterlady 10]

Hi Joymarie,

That's sounds like your insurance is just being a stickler. I'm going to west medical also and had no problems at all. A friend of mine referred me and had none either. I'm doing all my pre op in my home city. I will say that I've been extremely active in every step. I informed my pc and she agreed I was a good candidate. Once I heard that I was calling all parties to get things faxed over to each other and making phone calls. West medical have been amazing and were, equally happy with how active I was in making sure everything went as smooth as possible. That's just me I have to know what's going on every step of the way. I'm thinking it's a little ocd, lol! But heck I need to know because I have children I want to keep living for. I have bcbs and they only require 1 month before surgery but I decided to wait 3 so I can take my time preparing everything. I hope your insurance gets it together for you. Maybe you primary care doc didn't send something?

[wannaBthinsoon 1,634]

Worst case scenario is you have to do 3 months of face to face visits. Really..that's not bad. It sounds like a lifetime to someone waiting for the surgery, but it will go faster than you think. The end result is worth all the hoops. I promise.

[Joymarie333 41]

I had trust in them knowing the requirements I praying that whatever they faxed over today will get me approved if I have to another 3 months then I guess I have no choice thanks lady's for responding ????

Same thing happened to me last month. They called me to tell me I got denied because of the same reason... I was so pissed off. I have to do 6 months of weigh ins...so now I'm looking to get surgery January or February of next year... I'm not as bummed anymore because I understand this will benefit me in the long run with my eating habits. Good luck!!![/i wondering if I have to do the 3 months over, how do I submit to insurance turn paper work in under the same claim appeal it with new paper work or submit a new claim

[Rose4 Life 19]

I was given a packet that had all the requirements that should be met. Cindyw41 is correct we have to do our homework even when it comes to our Surgeon . Through it all don't give up.

[Susan66 128]

I will be calling Health Republic of NY tomorrow, my insurance carrier. I know I need 6 months of a supervised diet but I want to be sure who they want supervising, PCP or Surgeon?

[Rose4 Life 19]

Great @@Susan66 stay encouraged!