Aetna Question......

[boltsoros 0]

Quick question that I'm hoping somebody can help me with..............I am a borderline candidate for weight loss surgery; my BMI is about 38 with a couple of co-morbidities..............I have Aetna insurance and I went through an entire 6 month program at Geisinger hospital to have this process done. They kept telling me with every visit that I needed to keep my weight about where I started, 296.....I would fluctuate up and down a couple of pounds throughout the program, and they assured me I would be approved. I submitted my pre cert to the insurance company in December of 2015 and got denied in early January because I had actually gained 3 pounds during the program. I wish I had know the criteria, or at the very least the hospital would have.

The hospital suggested that we do a 3 month weight management program to show the insurance company that I was capable of losing the weight....we submitted the appeal at the end of April and it came back with the insurance company upholding the appeal based on the original weight gain. I have since been back to the hospital to continue my weight management program and have been doing very well holding my weight steady. My question is this............Can I submit a completely new pre cert since it has been 6 months after my original denial? Does it matter that I was appealing during this 6 months? I just called Aetna and the operator on the other end told me to submit a pre determination with the new information..............is there a difference? My hospital insurance lady doesn't seem to have a clue; the ball is in my court to make this happen.....she will re submit if I want her to.

Any help would be great.............I have been working to get this surgery for 13 months now...........it's really getting frustrating.

[Walter Lindstrom 42]

Sadly this has been going on for a long time. Here is a link regarding a similar situation (not Geisinger but with Aetna) which may help: https://wlsappeals.com/2142/walters_bariatric_surgery_blog/gained-weight-pre-op-diet-now-what/