Denied

Has anyone fought AETNA on the 6months of dieting over the 2 years ago and won?

Sue, I've been fighting Aetna for over a year. I was denied twice because I hadn't had a physician directed diet. So, for the past 6 months I was on one. When I re-submitted my request a couple of weeks ago, they denied it again because they said I didn't see a nutritionist as well. My denial letter didn't say anything about a nutritionist, just the diet, so I finally got approved on that technicality. I've heard Aetna is the hardest company to get to approve this surgery. If I were you, I'd read what the requirements are that are listed in your denial letter (probably another 6 month diet with a nutritionist and doctor) and follow those requirements to the letter and re-submit. Sorry to hear about your trouble, but they're hard to fight on a denial. Jules

Sorry Sue I don't have AETNA but I just wanted to say good luck and don't give up. I am pre op too and waiting now for all of the tests to be done. I will keep my eyes open and let you know if I here anything else about AETNA.

Thanks for the kind words. I have had all the testing done, taking AETNA at its word that previous dieting with my PCP 5 years ago would count. I have been waiting on AETNA since August and in NOVEMBER they tell me "We made a mistake, you must start over with the dieting" I have a lawyer and we are trying to appeal but again, I've been waiting since December 17th for a reply from them. I don't trust 'customer service' reps any more!

Sue, I know someone from Aetna told me this just recently as I was fighting with them. If they have a request and it doesn't meet the criteria, they shelve it for as long as they can (in other words, take the full 30 working days to make a decision, which is always a denial). When I first started this over a year ago it took them over 2 months, I finally called and then they told me they hadn't received anything...after I had called and called almost on a daily basis for those 2 months. Then when I appealed, they just "shelved" it until the time came to deny. If I were you, I'd get started on the 6 month diet and be sure to get a nutritionist involved. At least this way your'e ahead of the game because they're going to take their sweet time letting you know any decision. I wish I could give you good news, but after my struggle with Aetna that's about all I can see that you can do. Keep Fighting!! Jules

I think it would probably take longer to fight it than it would to just do the 6 month diet. This has been one of their requirements for more than a year. If you haven't already been to Aetna's website to check out all of their requirements - here's the link. http://www.aetna.com/cpb/data/CPBA0157.html If you haven't met all of their other requirements (nutritionist, exercise regimen, psych consult, etc.), you can use the 6 months to take care of those too. The main thing is to make sure your PCP documents EVERYTHING in your actual medical records. A letter from him to insurance probably won't be enough. Make sure you get monthly weigh-ins, take copies of your nutritionist/dietician notes to him and have him document that in your records. It just has to show that he is supervising every aspect of your attempted weight loss. Have him "prescribe" a low cal/low fat or some type of diet and note that in the records, make sure he "prescribes" some sort of exercise (walking, swimming, - something) and he should note that in records also. Feel free to contact me directly if you'd like. I have Aetna and was approved by them with no trouble because after I met their requirements. Good Luck.

Your best bet is ask then up front what all is required to have this surgery