Help understanding Aetna Denial language

zetabeans
on 11/7/06 11:11 am - Atlanta, GA
I need a little help understanding some of the language in my denial letter.  "After review of the imformation submitted, the cir****tances of this member and Aetna's Clinical Policy Bulletin: Obesity Surgery, coverage for the proposed obesity surgery is denied. The information does not indicate the presence of morbid obesity that has persisted for at least 5 years, which can be defined as either: (1) BMI exceeding 40 or (2) BMI greater than 35 with any of the following severe medical conditions: coronary heart disease, type 2 diabetes mellitus, obstructive sleep apena or hypertension. And the information recieved does not document participation in (1) a physican supervised nutrition ans exercise program of 6 months duration in the last 2 years (includign dietician consultation, low calorie diet, increased physical activity, and behavorial modification), or (2) and organized multidiciplinary program in preparation for surgery of at least 3 months duration. A physician's summary letter is not sufficient documentation. This coverage decision was based upon the general exclusiond described in the Booklet-Certificate." What does this mean.... that even thought my BMI is now 40 they will still deny me because they do not conside 5 years of diet medication, diets, running and training for 5 and 10 k races, 3 months of exercise bootcamp; all montiored by my doctor and the treatment of injuries and asthma issues as a physician supervised weightloss program.. Am I going to have to do 6 months of dieting only to drop my BMI below 40 and still get denied? Help can somebody tell me if there is some place besides the surgeons office I can have look at my documents and Aetna's policy to see what I really need, cause nobody will give me straight answers. - Really confused
Merredeth
on 11/7/06 11:25 am
I hate to be the one to tell you this, but your insurance carrier is requiring that you be on a six month multi-disciplinary road to yet another possible denial UNLESS you have some co-morbidities to help you get the surgery.  Yes, you will need to see the doctor every 30 days for six months. Yes, you will need to work on some form of excersize program as well.  I am a severe asthmatic (and even lost my 11 year old daughter due to her asthma that she inherieted from me) and we put in my plan that just walking in the mall for 30 minutes a day would be something that could count as physical activity until I could do something that would allow me to have more stamina.  Wishing you luck. Insurance companies suck. Believe me, if I posted my war story about a self-funded, self-insured national food company the wars that have gone on between me and the !@$$#^% of a human resource manager who is "the client" you would be ashamed to have any of their foods in your cupboards. I know I sure am.
(deactivated member)
on 11/7/06 12:03 pm
(deactivated member)
on 11/7/06 12:08 pm
Sean_B
on 11/7/06 12:09 pm - Schenectady, NY
seems that this is part of it:
The information does not indicate the presence of morbid obesity that has persisted for at least 5 years, which can be defined..... basically, you're "newly fat".... you're only recently (less than 5 years) considered to be MO, therefore you haven't really had time to sufficiently try to lose it.

Pre: 324 Now: 185-190 http://photos-h.ak.fbcdn.net/photos-ak-sf2p/v362/171/99/1251208761/n1251208761_30154298_7588.jpg

tracyburch3
on 11/8/06 2:34 am, edited 11/8/06 2:39 am - cinti, OH
According to Aetna's clinical policy bulletin, you have 2 choices.  You can participate in a 6 month diet with your family doctor or you can complete a 3 month multi-disciplinary approach diet.   None of our patients ever do the 6 month approach. This is what needs to be done for the 3 month version: 1) meet w/ a doctor monthly for 3 months 2) meet with a dietitian monthly for 3 months 3) keep exercise logs (you can print a calendar off yahoo and just jot down what exercises you do) for 3 months *Because you are required to see a doctor and dietitian, if your surgeon has one (a dietitian) on staff-you are better off just going to that office for this diet. It is very important that all visits MUST occur in consecutive months. Good luck and I hope this helps! Tracy Burch Office Manager/Insurance Specialist Dr. Trace Curry's Office  513-559-1222 [email protected]
zetabeans
on 11/8/06 6:33 am - Atlanta, GA
I understand what you guys are saying... I have been yo-yo'ing for 5 years because I have been trying to lose weight traditionally. I was also following my doctor's instructors for diet and exercise to reduce my risk of developing diabetes or heart disease which runs in my family on both sides. This is not a step I am taking lightly, I did the first surgeon siminar in January then did a 6 week running program folloed by 3 months of an intense workout bootcamp. These programs all required me to get my doctor to agree that my asthma would not interfere. I spent well over $1000, got up everyday for 3 months at 5 am, followed a very strict low calorie six meal per day diet using a daily food and exercise log. After all of that I lost 11 inches in my waist and a total of 8 lbs. It was then that my doctor recommended that I pursue the surgery and he placed me back on diet medication. From June to August I did my initial consult and all of the pre-op/pre-cert testing. During the bootcamp I saw my doctor 2 of the 3 months and we exchanged progress emails. This is a practice he and I established when I started taking running classes in 2004 as well as when I trained to run the Peachtree Road race (10K). From 2001 to the present there is very little time that I have not been on some sort of medication for weight loss perscribed by my doctor. It seems that I am in a catch 22, if I do another six month program and loose weight my bmi will be below 40 and because I do not have any of the co-morbidities they will not approve me.  I am going to do a second sleep study this week as my doctor is hoping the my mild sleep apena may be worse. My last cardio stress test was a joke because I was able to run for over 45 minutes with no problems.  I know I sound like I am whining, but it really crushes me to know that if I had done nothing and let myself develop serious help problems that this surgery would probably get approved.
scottm
on 11/9/06 2:50 am - Little Elm, TX

Here is a question or two to see if I understand where you are.

 

Have you been morbidly obese for the past 5 years or more?

 

Also in the past 12 months were you seeing a doctor for weight loss for a 6 month period?

 

To me it sounds like you were.  The issue could be here that everything was not documented well enough. 

 

Let me know a little more..

 

Scott

Jamie Wilson
on 11/9/06 11:50 am - Round Lake, IL
Hi there! I have Aetna as well and recently read through the service bulletin myself and read all of the same exact language. I have been overweight my entire life, I was always the chubby girl in grade school even and I'm 34 now. I have been thinking about this surgery for years so I certainly understand and can relate to how you feel. My BMI is 44. Three years ago I was working with my dr, checking in regularly and lost 40 pounds, which I have kept off since but haven't lost anymore. Unfortunately I can't use that as my supervised diet (I'm guessing) since it was more than 2 years ago. For what it's worth, here is how I look at the three month *waiting* period (and this may just be my wacky thinking) but it's like being engaged before you get married. That engagement period allows you to plan the wedding and go through the steps but back out if it's just not for you. To me this surgery is in a way like marriage and with some good counseling and prepatory steps, including a lot of brutal self honesty, it can be a good solid marriage or without the right preperation your chances of failure are just that much higher.  I know it's hard, but try to take the time before the surgery to really focus and center yourself mentally (not saying you aren't already, please don't get me wrong) but it's a great time to prepare for this huge life change. It's a great time to work on breaking some of those habits and routines that we have been stuck in and to start to change our entire relationship with food before the surgery. In the grand scheme of things, three months isn't that long. I've been overweight for 34 years, I can wait three more months. It will fly by faster than you think.... I promise. Just remember, think of it like an engagement period. A 3 month engagement is pretty short!
Jimsbride
on 11/9/06 12:22 pm - Cumberland, MD
I am glad to have found this thread. This answers alot of questions for me. However, I heard that Aetna MAMSI requires the 6 month cert., I looked at my card and it does not say MAMSI. Does that make a difference? Also, this thread is the first that I have heard of a 3 month period. I called Dr. Afram's office and they told me only of the 6 month and did not ask about MAMSI? Can anyone clarify? Thank you Jimsbride
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