Your Aetna experience?

[circa 0]

:omg:

I am soooo scared after reading all of your posts!!! I have Aetna POS II, and am doing the 3 month Nurse Pract/Dietician weight loss visits. I will be done with those mid-March. I have a flow chart from the Dr. office in another state for 2003 and 2004 and from a gyn and pulmonologist for 2005 and from my ob dr. for 2006 and from my PCP for 2007 and 2008. Will that make a diff that they are all from different places? I also have sleep apnea and have a BMI of 48.

I wish you all luck!!!! :clap2: Hopefully I will get approved. :nervous

Kristi

Don't be scared! If you meet the criteria, they won't deny you. You just have to make sure that you do meet it. It absolutely doesn't matter where the records for your history come from - Mine are from about 10 different doctorts in 4 states and that's not a problem. You just need to make sure that your however many months of attempted weightloss are from the same place

Besides, mine's not an Aetna issue, its an incompetence issue with an office person at my center.

[Tigger_Shorty 0]

Did any of you get the pre cert letter that tells you what they are looking for?

I did and circa if you have other medical issues that are effecting you don't panic. They look at the whole picture. I went thru a lot to get approved only because of the office person not knowing what she was doing.

Keep your head up! And if they do happen to deny you for one reason or another just keep after them don't give up. I did that and I am having surgery on 1/23. I will pray for you!

[circa 0]

Okay, I just got off the phone with Aetna. Lemme tell you something about Aetna. I have had NO problems with them. They have approved things that most insurance companies still consider experimental. They had no problem with me switching to a birth control that they don't cover (and is WAY more expensive) because its the only one on the market that doesn't contain copper as a binder (I can't have copper). They've paid for weekly infusions and "experimental treatments" because the treatments I need for the medical condition I have, I'm allergic to. They didn't blink twice. All I had to do was send a letter from my doctor with my official diagnosis along with my medical indications - allergies, etc. and they rubberstamped it. I have had NO issues with them. I just got off the phone checking the status of my appeal. I explained to them that I wouldn't be in this situation if the center had sent the records in the first place. The Aetna lady put me on hold and physically walked the documents that were missing over to the reviewer and told him to get on it ASAP. She was very reassuring and even apologized for the mixup, even though it wasn't Aetna's mixup. I haven't been approved yet, but I know if its up to Aetna, I will be. Unfortunately, its not just me an Aetna, I have to deal with people who are less than adequate at their jobs as well...sortof Monkeys in the middle, I guess.

Just relax and know that if you follow up and you meet the criteria, they will approve you. Sometimes it might take an appeal or two, due to the fact that something isn't quite clear and needs to be explained, but overall, I can't say enough GOOD things about Aetna. I had BCBS of Alabama once. Yeah - they can go suck an egg. They wouldn't pay for birth control, but they'd pay if I wanted to pop out 15 kids. Geesh

[bostonbabe 0]

Yikes---Do you have Aetna Choice POS II? that's what I have and I weigh the same as you----I'm afraid that is what they are going to say to me too!!!!

[EnchantedRuby 0]

I just got approved by Aetna today.. It wasn't very hard. It took me calling everyday to be sure it was being worked on. Aetna got my claim on the 9th and I got approved today so although it felt like forever it really wasn't. I have Aetna Choice POS II.

[skculpepper 0]

I just got approved by Aetna today.. It wasn't very hard. It took me calling everyday to be sure it was being worked on. Aetna got my claim on the 9th and I got approved today so although it felt like forever it really wasn't. I have Aetna Choice POS II.

Congratulations, EnchantedRuby! I have the same insurance as you, I was approved rather easy as well, I am scheduled for January 25th. Good Luck to you!!

[ksb37us 0]

I was wondering if I have any chance of getting approved with Aetna Choice POS II. My BMI hasn't been 40+ for 5 years. It's been 35+ with me also having hypertension. Right now my BMI is 41. The Bariatric Coordinator at my surgeon's office is almost positive I'll get denied because of this.

[circa 0]

I was wondering if I have any chance of getting approved with Aetna Choice POS II. My BMI hasn't been 40+ for 5 years. It's been 35+ with me also having hypertension. Right now my BMI is 41. The Bariatric Coordinator at my surgeon's office is almost positive I'll get denied because of this.

Have you gone through the 6 month weightloss with a physician? Do you have the 5 years of documentation of your BMI being 35+? If you do, they can't deny you. It follows the clincial policy bullitin

Obesity Surgery

Selection criteria:

1. Presence of severe obesity that has persisted for at least 5 years, defined as any of the following:
   
   1. 
      
   2. Body mass index (BMI)* exceeding 40; or
      
   3. BMI* greater than 35 in conjunction with any of the following severe co-morbidities:
      
      1. Coronary heart disease; or
         
      2. Type 2 diabetes mellitus; or
         
      3. Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea); or
         
      4. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);
         

      and

      [*]Member has completed growth (18 years of age or documentation of completion of bone growth); and

      [*]Member has attempted weight loss in the past without successful long-term weight reduction; and

      [*]Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary surgical preparatory regimen):

      1. Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet all of the following criteria:
         

         or

         [*]Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three months duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions:

         1. Consultation with a dietician or nutritionist; and
            
         2. Reduced-calorie diet program supervised by dietician or nutritionist; and
            
         3. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
            
         4. Behavior modification program supervised by qualified professional; and
            
         5. Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.)
            

      
      
   4. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
      
   5. Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least three consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.); and
      
   6. Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records;
      

[ksb37us 0]

I just started the 6 month weight loss with my doctor. I'll be done with that in July. I have documentation from my doctor stating I have a BMI 35+ for 5 years. I meet all the criteria that the insurance needs. The Bariatric Coordinator says they will deny me because I don't have a BMI of 40+ for the last 5 years. She said she'll submit all my paperwork to the insurance when I'm done with the supervised diet but she knows I'll be denied.

[Peachy116731 0]

:mad:

Hi everyone!!..I'm new here..been here ALL Day, going through the forums...and I am one of the "lucky" ones to have Aetna insurance.

All I have to say is...thanks for the heads up on things needed for approval...although I havent settled on a surgeon..( narrowed to 2) I wanted to know exactly what I am getting into before I started...lol...but sure there will be a few surprises along the way.

I'm sure I will be here alot during my journey..for support..and to vent!!

Good Luck to all who have been approved, all who are pending approval, and all who have had the surgery!

OH...btw...Has anyone used Dr. Richard Carter?...need some input here...a friend of mine used him...she was very pleased...:tt1::mad::mad::mad:

[jenniferann6 0]

Wow, I've learned alot about Aetna and what to submit-I've been working on it since mid November-I'm doing the 90 day diet/pcp thing.

Here's my question: We've been insured by Aetna for about 5 years or so-for the last two years, we've tried to increase my life insurance policy. I've been denied for the last 2 years due to height/weight ratio-instead of going for the max amount, we did it just one step higher this past year, and was still denied for the same reason. When I submit my stuff, should I also submit copies of the denial letters from them regarding the increase in life insurance denial?

I'll call on Monday and check with the surgeon's office as well-they've been great! Thanks a bunch!

[kimillionaire 0]

I am going through the same thing. For me to do the supervised diet and all the non-sense is around $1200.00 so I don't want to spend the money if I don't have to. I am only missing one year in between but can prove over six years just not all in a row. Good luck!

I have Aetna and my supervised diet is 3 months. I have to pay a $15 co pay for the 3 dr. visits and $150 total for 3 dietician visits. The lab work and stress test is included. Why do you have to pay so much?

[polly522 0]

I am new here and have been reading all day! I have a few questions: I am 47F BMI 39.7. The doctor last year (6/07 put me on South Beach Diet, due to being diagnosed with Diabetes. I have had gestational Diabetes 7 to 10 years ago, with both my kids. The only reason I found out is because I requested to have full blood workup in June done. I have had thryoid disorder for the last 8 years, and knew something was wrong (sibs have diabetes), so that is why I requested the test. My BMI has been up and down 35-40 for the last 7 years. Will Aetna count the diet he put me on last year, or do I need to do it all over again? I am about 100 lbs overweight. Is Aetna going to deny me also? My doc recomended this last year, but was really scared, went on the diet, and lost 30, but have gained it right back plus some! I live in Nevada and need to find a good surgeon.

[circa 0]

I am new here and have been reading all day! I have a few questions: I am 47F BMI 39.7. The doctor last year (6/07 put me on South Beach Diet, due to being diagnosed with Diabetes. I have had gestational Diabetes 7 to 10 years ago, with both my kids. The only reason I found out is because I requested to have full blood workup in June done. I have had thryoid disorder for the last 8 years, and knew something was wrong (sibs have diabetes), so that is why I requested the test. My BMI has been up and down 35-40 for the last 7 years. Will Aetna count the diet he put me on last year, or do I need to do it all over again? I am about 100 lbs overweight. Is Aetna going to deny me also? My doc recomended this last year, but was really scared, went on the diet, and lost 30, but have gained it right back plus some! I live in Nevada and need to find a good surgeon.

It really depends on how its presented to Aetna, would be my guess. If your doctor has documented 6 months of weightloss visits (3 of which are consecutive) in the last 2 years. If you have that, you'll meet the requirements

[EnchantedRuby 0]

Congratulations, EnchantedRuby! I have the same insurance as you, I was approved rather easy as well, I am scheduled for January 25th. Good Luck to you!!

Thank you I just got my surgery date yesterday.. it is scheduled for the 7th of February.