Meeting the Requirments

[LynnAnn 0]

My medical insurance is through Aetna. They will pay for half the cost of the surgery if I meet all of their requirements. When I call they point me to their policy bulletin on line and tell me to discuss it with my doctor for clarification. When my doctor reads the policy she says that it could mean different things. For example, one of the policy items is an ‘Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional.’ OK, I have been attending Curves for a year and a half, but I wouldn’t call the people working there a qualified professional. My doctor says that Curves is wonderful exercise for me and that this would meet the requirement if it were up to her. Does my doctor count as a qualified professional in this case since she is monitoring my progress? If I bring my doctor a printout from Curves showing my attendance will this meet Aetna’s requirements?

I can’t get Aetna to say that this will or will not meet their requirements. If I wait until I go to get approval and find out that it wasn’t what they had in mind I will be very frustrated and angry at having wasted all that time. Does anyone have any advice on how to get Aetna to be specific?

Thanks, LynnAnn

[Alexandra 55]

Your doctor can count as the "qualified professional" if she's been following your activities and progress at Curves. Presumably you've been seeing her regularly for weight checks, and she's also been recording your other vital signs. She could write up something about the specific effect your Curves regimen has been having. If she could drop the phrase "pulmonary reserve" in somewhere that would help.

Unfortunately, you won't know if this will really satisfy them until you try. But from my experience, I think it will.