Aetna Insurance Question

Hello everyone! I am currently in the process of trying to get approved for WLS by Aetna; I have completed all of the 'requirements' and am on the 6 month medically supervised diet, because I completed the 3 month multi-disciplined program and was denied. Does anyone have a great appeal letter specifically for Aetna? Thanks for all of your help in advance! :)

Aetna specifically requires a few things for the surg prep program.  It has to be a minimum of 90 days long, you will be denied for 88. You have to have a letter from the doc, stating you have begun the surg prep program on this date. Then you see the nut monthly for documentation, then the doc writes a letter at the end, saying Susie completed a 90 day surgical prep program whi*****luded monthly visits witht the nut, tips on exercise and behavior modification....blah...blah..blah...she was compliant and I recommend proceeding with surgery. All that is written in the criteria (says something about a doctors assessment at the beginning and end of the program) and if you are missing one piece, you get denied. You are probably a few days short or missing one of the 2 docs letters. Bonnie

thanks for the information! we will resubmit soon!

Does Aetna call your PCP or surgeon's office for more information if needed or if they have questions, or do they just deny and move on? I guess my question is do they go off of what is in your file that is submitted or do they request more documents or originals of the submitted info?

Unfortunately, it depends on who is reviewing your case. I have been called by Aetna for more info, and exactly what was needed was explained to me. That is how I learned about the letter needed from the doctor AFTER completion of the prep program. I have had other denials in the mail, though, with no warning or opportunity to send more info. Good luck! Bonnie

Just curious - because I have Aetna, also - did they tell you why they denied your 3 month multidisciplinary regimen?

Wow!  Reading this thread gave me deja vu!  I started my journey in December '07 and had my psych, labs, dietician, physical therapist and surgeon exams all done on one day.  The surgeon submitted everything to Aetna and within two weeks it was denied.  First let me preface this by saying I am 50 years old, I am at 42 BMI and have hypertension among other co-morbidities.   My surgeon explained to me that my insurance was requiring a multi-disciplinary 90 day program before they would approve it, so I began that in January and continued through til the end of March (still counting my appointment in December).  The second appeal was resubmitted again the 1st of April and again was immediately turned down saying that I did not meet the 90 day multidisciplinary program and told me that I needed a 6 month physician monitored weight loss program.  My surgeon has not returned my calls since.   I took it upon myself to call my PCP and we had our first appt on 4/30.  I had printed out all of Aetna's information and he told me what I needed to do.  In the meantime he prescribed a sleep study and back xrays (since I've had a lot of problems with my ciatic nerve).  I went back last Friday for my "30-day" checkup and I've lost 10 lbs.  I provided him with an entire printout of my meals each day along with my exercise program.  My initial sleep study showed that I have severe apnea and my back x-rays showed that I have some degeneration going on in my lower lumbar area causing the stress on the nerve.  He does not however want to do back surgery because he feels that when the weight is off, it will change the entire alignment of the spine and the results of the surgery.  He instead prescribed pain pills and a more complex sleep study to determine the degree of apnea.  He also was very upset with the insurance company "dictating" when someone can have surgery or not.  He feels I am not getting younger and the longer I wait, the more damage it is causing.  He also recommended Gastric RNY rather than the Lapband. His thoughts are to resubmit everything again to the insurance in July and hope that they will reconsider the appeal again.   By then it will be 6 months since I began my journey but only two months with a physician monitored program.  Do any of you have any suggestions or ideas on how to get this to work?  Is there a specific letter, verbiage or form that he should use?  Any advise would be appreciated since my surgeon is no longer providing me with any assistance.  His nurse just said that I would have to wait the six months....and therefore I think she washed her hands of me until then.

this is so frustrating! & even more so to read others dealings with insurance.... i started everything in dec 07 as well, and completed EVERYTHING, submitted to aetna, only to have them deny me 3 days later... i am frustrated because when you call and try to get an explanation why, they give you a brief explanation, and then if you ask details, or questions, they are not allowed to discuss the WLS clinical policy bulletin with you... only the DOCTOR is allowed to, and the dr will only speak with another dr. frustrating! i completed the 3 month, and was denied even though my bmi is high enough, and i have co morbidity's, & have letters from my surgeon, and primary dr, along with the dietitian that i see every month... i am resubmitting again this month since it will be the 6 month... now, i just have to come up with the 2,000 for the yearly maximum out of pocket. agh.... one day! :) thanks for posting on here, i appreciate knowing that i am not the only one going through this... take care.

oh! aetna just denied me without really telling me... i called, and then they told me, and then a month letter i received a denial letter. & they are not allowed to say WHY they denied my 3 month program. :(

Remember, even if you do the 6 months to make sure it is MORE THAT 180 DAYS! If you see the doctor 6 times, it doesn't count unless it is more than 180 days. They will deny for 178 days.