Aetna - 5 years documentation??? Help!

[BrooklynBandster 0]

Hi, all you friendly and helpful folks - I need your help. I've heard from some sources that Aetna requires documentation from a physician of each of the past five years of obesity, and from others that they didn't need this. (I don't have that documentation, though I've been obese for over 20 years.) Is this going to stop me from getting coverage?

Also, I've now heard that a bunch of people have gotten approval using the 3-month multidisciplinary diet/exercise program. For anyone who has: did you need documentation from an exercise specialist, nutritionist, PCP, and mental health person? Or just the last three? And if I've been seeing a therapist for years but she's not in-network, could she still count in that program?

I appreciate all your help in advance! :ranger:

[cbrock1592 0]

I too have Aetna.

I tried in 2005 to get approved, but got denied.

They do require 6 months dr approved diet and exercise. I did it through my Dr's office with a nutritionist. She would track my weight weekly during this period. I found out afterward that the surgeon's office started having a monthly meeting to do this.

My dr and nutrionist also submitted letters on my behalf stating that I was a good candidate for the surgery and what would happen if I did not have it.

I also submitted my weight watcher records from 1998-present which I had many logged weights to show my weight goes up and down like a roller coaster.

The nutrionist and pychologist appts I did through the surgeon's office. They have people that work with you on this requirement.

I was approved 3 days after paperwork was submitted.

Good Luck!

[KtKt 0]

I'm on the Aetna wagon too... I've never heard about 5 YEARS... unless it is to prove that you've been ow for 5 yrs or more... that should be in my medical records...

My understanding is a 6 month supervised diet & exercise plan... which my Weight Loss Team recommends anyway...

[cbrock1592 0]

Here is Aetna's policy bulletin on their website:

Obesity Surgery

This may help.

[MissNilsa 0]

Hi ListenHard:

I just got approved after appealing a denial from Aetna. I was supposed to have surgery 6/18/07 and they denied me 2 days before my surgery after I was already on my liquid diet. What they require is a minimum of 6 mons of diet/nutrition/health records in the form of a letter or something legible. I have been with my primary care physician for 20 years and he has been treating me for obesity since 1995. Aetna had the nerve to try to deny me even though they had those records because my doctor wasn't writing enough detail for the last 6 months. I had to do the 6 months because alhtough he has been my doctor for years, they still want 6 months minimum, back to back.

anyway, we did an appeal in letter form with all of my history, medications, diet pills, diet advice and all that good stuff. We did it in Word format in a table and so the denial got reversed and now i'm having my surgery 8/13. They just don't want to pay and they will make it really hard for you if they can. Let me know if you would like a version of the letter that we used. I can take out names and information and send it to you so you could show your doctor if you want.

thanks

[MissNilsa 0]

Here is Aetna's policy bulletin on their website:

Obesity Surgery

This may help.

hey: congratulations, your surgery is coming up this week. you did loose a lot on your own! good luck.

[MissNilsa 0]

You are right. It must be detailed though because Aetna will not hesitate to deny you for the slightest reason. They are very very good at that.

[BrooklynBandster 0]

Thanks, everyone. I've heard from so many people who've had enormous problems getting covered by Aetna, and others who got approved with no problem a few days after submitting. So much of it seems to be just up to the whim of whoever reviews it. So frustrating.

[cbrock1592 0]

At this point - you have nothing to lose. Aetna will tell you why they are denying you.

At that point - you have to make sure to give them what they require.

Good luck in your journey! =)

[MissNilsa 0]

Thanks, everyone. I've heard from so many people who've had enormous problems getting covered by Aetna, and others who got approved with no problem a few days after submitting. So much of it seems to be just up to the whim of whoever reviews it. So frustrating.

My surgical coordinator told me the same thing. The reviewer who denied me was a nit picker and he wasn't budging at all even though he had all the information and my records dating back to 95 regarding obesity. But that is over and done with.

[vallin 0]

Cbrock you have lost alot of weight and have not been banded???? Wow that is wonderfull! Your band date is 8/1/2007?

[cbrock1592 0]

Yes - I did alot of it on my own through diet and exercise. I actually started the exercise first - then the diet came later. It came off very quickly at first and then I got stuck in a rut after having a baby in 2003. I originally applied for surgery in 2005 and got denied. I applied again in May 2007 when I got all the requirements done and I got my act together again and had recently lost weight and then I got approved. Go figure! My doctor and I still agree for long term success to follow through with the band. Tomorrow it is. I'll let you know how it goes!

[NanaRenan 0]

Hi! I had to give 5 yrs. But all I did was contact the different doctors and get them to fax my surgeon's office with a date and a weight from my chart for the year they saw me.

It shouldn't be hard if you visit a doctor once a year and they take you're weight while you're there. Any professional, in network or out, who will vouch should 'count'.

I did my three months by seeing the nutritionist at my surgeon's office, then I could weigh once a month at my family doctor's office instead of driving across Houston to the surgeon's office. Fortunately, I also had them weigh me each time I went there for other things -- like a sinus infection! Because by the time Aetna came back and said they wanted SIX months instead of just THREE, I was already in the fifth month!

I think what tipped the scales (pardon the pun:D) was that the last time they submitted it, they asked that it be reviewed by someone who specializes in bariatrics look it over. They came back with a Yes after only 7 days.

[SkinnyChick 0]

Hi ListenHard:

I just got approved after appealing a denial from Aetna. I was supposed to have surgery 6/18/07 and they denied me 2 days before my surgery after I was already on my liquid diet. What they require is a minimum of 6 mons of diet/nutrition/health records in the form of a letter or something legible. I have been with my primary care physician for 20 years and he has been treating me for obesity since 1995. Aetna had the nerve to try to deny me even though they had those records because my doctor wasn't writing enough detail for the last 6 months. I had to do the 6 months because alhtough he has been my doctor for years, they still want 6 months minimum, back to back.

anyway, we did an appeal in letter form with all of my history, medications, diet pills, diet advice and all that good stuff. We did it in Word format in a table and so the denial got reversed and now i'm having my surgery 8/13. They just don't want to pay and they will make it really hard for you if they can. Let me know if you would like a version of the letter that we used. I can take out names and information and send it to you so you could show your doctor if you want.

thanks

Hi MissNilsa,

My name is SkinnyChick (hopefully soon to be)

I am new to this messageboard, however, I am with Aetna as well and decided to do a little research before I submitted my papers. I found out today that my plan does cover the operation however, I am considering submitting everything the first time. Would you mind sending me a copy of your 6-month documentation (SkinnyChickToo@yahoo.com). Since it worked for you I would love to see an example of what they are expecting.

Thank you so much for all of your help

SkinnyChick

[als995 0]

Hi MissNilsa, would you mind sending me a copy of the letter as well. I am new to this forum and actually just recenty started considering the Lap Band. I have Aetna, and I figure, I better be safe.

Thanks alot.

Als995@hotmail.com

:car: