Aetna Pre Op Diet

[ocbreeze4u 0]

I have only been on this site for a few days and I have Aetna PPO Choice. I have read MANY times that Aetna required a 3 month diet and I did not need to do that for approval. What is the purpose of the diet and why do they require it for some in order to get approved? Just curious:confused:

[Jodi_620 37]

Most require it to document your efforts at losing weight and to see that the person is willing and able to make the changes that will help them be successful at losing weight.

[MicheleK 8]

I just finished my Aetna diet...thank God! It's annoying but if it gets it paid for, it's worth it. :tt1: I'm on pins and needless now waiting for approval.

They used to require a 5 year weight history also...thankfully it's only 2 years now. Oh, and I also found out today that they don't require a psych exam unless you've been under a doc's care for more then mild depression (not sure if that's new or not).

[ocbreeze4u 0]

I knew about the 2 years of a high BMI and I did not have to do a psych evaluation but I also did not need to have a pre-diet. Other than the two appeals regarding my BMI dropping below 35 BMI in the last year (it only dropped .04% to 34.6 BMI) and I was below by only ONE POUND, I did not have to "jump through hoop" as I have heard from some. Maybe it depends on the nurse reviewing each individual case at Aetna or maybe it was because I was already on a Doctor supervied diet at the time my case was submitted to Aetna?

Well, at least this comfirms what I have always known that Aetna is NEVER consistant and you just need to know who to brown nose over there to get what you want:sneaky: LOL

[polly522 0]

Okay, mine was just submitted today for review by Aetna, after I HAD to go through a 6 month diet. So whom do I have to bown nose to get this approved the first time?:tt1:

[ocbreeze4u 0]

Hi Polly522

LOL, very funny. I have learned this...it is good to find out whom your nurse reviewer is and give her a call and do what it takes to give her a great impression of you. I was going to be approved the first them and I talked with the nurse that was reviewing my case. The day before she was to sign off she went on leave from Aetna and a nurse taking her cases was to sign off on it but instead she rejected it. I talked with the original nurse after the fact and she was frustrated as well because she approved it.

Please remember that Aetna automatically rejects 80% of all claims for Lapband originally but almost always approves on peer to peer reviews and appeals so be patient....it will happen.

After two appeals I was approved on June 11 and I got my letter in the mail last Friday and my surgery is scheduled for July 24.

Good luck!

[polly522 0]

How do I find out who my nurse reviewer is?????

[ocbreeze4u 0]

That is the hard part as Aetna gives you the run-around everytime you call. Call the customer service number on your membership card and ask that you speak with the nurse reviewing your procedure request for Lapband. If you are lucky, the representative on the phone will know what they are doing, if not then they will transfer you about three times. If that happens then ask for their supervisor and tell her what you need. Once you get the nurse (you will get her voicemail) make sure you get her extension number with first and last name so you will not have to fight with customer service the next time you call and leave her a message to return your call because you have a few questions. Make a list of what you need to know such as..

Am I missing any needed documentation?

Do I meet the qualification per your guidelines if not then what have I not met?

If you did not meet any criteria or they need some more information, ask if she will grant you 14 day wait to obtain the requested. They will and that will give you time to gather what you need instead of going through an appeal or a peer to peer review.

I had problems with my doctor's office handling my appeals as they screwed it up so my second appeal I handled all myself and told them (the doctors office) to bug out of it. I won in the end and I can honestly say the Aetna is very tough to deal with and I am in the healthcare industry!

Good luck and if I can help you in any way then please send me a private message and I will walk you through it.

[ndwife 0]

I had absolutely no probelms with Aetna. I was approved within less than a week. I did do the diet supervisd by my doctor and I had all my ducks in a row. I think that it all depends on the company that your Aetna insurance is through, not Aetna themselves.

[polly522 0]

Mine is through costco, so I am hopeing that this will be easy. And thanks for all your help! :embaressed_smile: