Needing some serious Aetna advice!

[christan007 0]

I could really use any advice or suggestions for my current predicament! I will try to make this as quick as possible...I have been jumping through Aetna's hoops since Septmeber of last year. I completed the 6 month medically supervised diet in the beginning of March. During that time I gathered all of the info needed, including nutrition consults, psych evals, and previous years weight history. I submitted all of this info to the surgeon's office and was told that the patient advocate/surgery scheduler would handle the insurance end of things. I did not actually witness my '06/'07 weights because they were faxed directly to the Doc. I had my surgical consult and a tenative date scheduled for 4/27. All I had to do was wait for the insurance to approve. I received a phone call from the patient advocate yesterday saying that Aetna requires that my BMI exceed 40 the last two years. (I assumed that it had, seeing as everyone told me that all my info was in prefect order). Unfortunately, in '06 I was coming off of a successful WW stint when I went to the Dr and only wieghed in at a measly 224 (ha). I have until Tuesday to prove that I have been indeed heavy since '06. I can prove '03-05 and '07-the present. What do I do? Anyone have any experience with getting something like this approved? I'm trying not to wish hateful things upon the insurance "gods"....please, any advice would be sincerely appreciated.

Christan

[PrincesaJenE 0]

Hmmmm, I have Aetna. I didn't have any problems like this. My doctor had a special team that worked on getting insurance coverage. What I would do is tell them just what you said in your post. If you could prove that both before 06 and after 06 you were heavy just submit a letter that says I went on WW and lost blank pounds. You should be able to submit the documentation for WW with your weigh in information. Additionally, tell them how you gained it all back and how you're looking for a long lasting solution that you believe you've found with the lap band. This is my only suggestion - but I don't see why it won't work. Good luck - I'd like to know how it all turns out.

[lindas0809 0]

I was just approved by Aetna last week and was approved with a 6 month diet history, psych eval, nutritional eval and a letter of medical neccesity from my Dr. Originally I was told I needed the two year history and finally got it from my old Dr., but my Surgeon coordinator turned in my packet before I gave it to her. I was really worried that they would deny me because of that but obviously I had no problems(maybe I'm so big they just know I couldn't have been below a 40 BMI in the last two years).

One suggestion I would make is to call the precertification number on your insurance card - that's who told me I was approved. They seemed more helpful than just calling the general number.

Good Luck- keep us posted!!!

Linda

[arizonafrog 0]

Well I have aetna and I can only tell you the hoops I had to jump through to get my band. (note: My bmi was well over 50 and the doctors scales would not get my wieght because they only go up to 350 or something so no documentation all just guessing) Well I pulled my charts from my 2 last pcp and then i did a sleep study which showed i have a slight case of sleep apnea, I also had high blood pressure and asthma,I went to see a cardioligist and did a series of tests, blood work, chest x-ray, ekg, physical, phsyc eval, nutrional eval and monitoring for 3 months with supervised diet and excersise, and then the eval from my WLS and that was it I started the whole thing on the 27th of july 2008 and was banded 3 months to the date on 10/27/08 I never even really had any issues I just did all the test the WLS told me to do and they did the rest. I do know that my WLS did spice up the eval he submitted to Aetna. Once submitted it took less then a week to get my responce. I dont know if all that info will help but that is what I had to do :thumbup: Have a great day and GOOD LUCK

[christan007 0]

Thanks for the advice everyone! I am going to call WW tomorrow and see if they have the records showing that I was indeed over a 40 bmi. I think the really frustrating part is that my WLS' office promised that they would take care of everything. The lady I have been dealing with admitted that she should have caught the problem sooner. I would have had the last 3 or 4 months to locate records of my heavier weights instead of scrambling to find something by Tuesday. Anyone had luck on appeals? I am terrified that Aetna is going to continue to jerk me around!

[TulipsRosie 0]

Hello Christian,

I have Aetna as well and I just got approved yesterday. I had to jump through alot of hoops too. At first Aetna only requested nutrition consults, and psych evals. At that point they denied me. I appealed and found out they also need 2year weight history. I provided that info on Friday afternoon and was approved yesterday. I am really not sure what the deal with all of this is, but I wanted to do what it took to get approved.

I know it seems hopeless and you want to give up, because that is how I felt. I even got depressed, but I kept at it and submitted everything they asked of me. They asked for 2 years weight history and I submitted weights for 2006 and 2008. I didn't go to the doctor in 2007 for some reason.

I know this isnt' much help but I hope it gives you HOPE. Good luck and sending positive vibes your way.

-Maria

[AliciaA122 24]

Good luck! I have Aetna too and am just starting the process.

I just met with the surgeon yesterday and have to decide if I want to do the 6 month doctor supervised diet or the 3 month multi-disciplinary program. If I do the 6 I figure I’d be banded late October/ or November.

I can’t decide which to do… so I’m calling the place that runs the 3 month program today for further details.

I'm leaning toward the 3month because it would mean being banded sooner and that's a good thing. But we'll see.

[silvers320 12]

Funny I had Aenta and they required 5 years worth of proof of my BMI. I still ended up denied and appealed both to Aenta and the state insurance department and won. Point being there is hope. I would think if you can get the medical records from the earlier years that would help your case.

[Goal150 0]

Aetna sucks! i went for over a year trying to get approval, got denied six times and i had to reapply. I just got my approval and i am scheduled for the 23rd. Give them all weight histories, anywhere yuo have gone to the Dr and been weighed for the last five years . Goodluck dont give up thats why they want people to do.

[AliciaA122 24]

If you don't mind me asking, why were you denied 6 times? Was it a lack of documented weight history?

[christan007 0]

Thanks for the advice and words of encouragment! I should find out today or tomorrow what they say. I submitted my WW booklets from those two years and a letter from my PCP saying that she didn't treat me for my high blood pressure or cholesterol due to the plans I was making to have this surgery. I am just keeping my fingers crossed and hoping that they accept this as proof of my higher BMIs. Like a lot of people, I don't go to the Dr. super frequently so it was hard to find documentation of my weights. Well, I will be back to let you guys know how it went. Please keep your fingers crossed for me!

[Goal150 0]

they claimed i did not show two years BMI the 1st two times which i did. Then the second time they said they wanted five years, i went and got all the records. Then they denied me since i sent it to the wrong address. Sent it to the appeal process and said that i had exhausted my appeal. Then My DR had appealed on my behalf and that had been denied as well. Then told me the 6th time that i had used all my options and i had to apply as a new patient. Went back to my surgeon and we reapplied and then i just got approved one plus year later. They were just giving me a hard time. I had to prove BMI of 42+ !!!!!!!1. Good Luck.