Aetna Insurance Question

good to know, thanks!!! :)

180 days from what start date?  The date I initiated this journey and had all of my initial exams? or the first day I went to see my PCP about this and he weighed me?  Can we count the three months of multi-disciplanary appointments?   I have to say at this point that the three month multi-disciplinary program was a joke.  My WLS had me meet with my nut and the PT once every month for three months, and all they did was go over what I will be eating when I have the surgery and what I should have my heart up to when I start my excercising.  They did not "put" me on any kind of a program. The nut told me to write down what I eat for 7 days and to bring it the next time which I did.  I have no idea what they submitted to Aetna but I can guess it was wrong and that is why it was denied.  I am concerned that my actual clock did not really start until my PCP weighed me and began the supervised program on 4/30.  If that is the case, I will not be going in for surgery until Christmas probably, since I have a cruise in November to go on....fat still. I am willing to do whatever it takes, but as you can probably tell I am very frustrated.  You put your faith in these docs to know what they are doing with the insurance companies, and I think mine just screwed it up even more.  Let me know if you have any comments.

Brenda-

my office does the 90 day program all the time and we are really successful.  90% approval rate for it! I learned a few tips from one of the nurse-reviewers at Aetna... it has to be a minimum of 90 days....88 days will get denied. The surgeon needs to write the letters (not your family doc) that says: Brenda is beginning a multidisciplinary surgical preparatory program in order to improve pulmonary reserve and surgical outcomes for baratric surgery (verbage taken right out of Aetna's policy). Her weight is...she will see the nutritionist monthly. She plans to do.....for exercise....

Then you get your nut eval and monthly documentation for the next 90 days of weights, nutrition plan, exercise, etc. Then, the surgeon writes another letter..."Brenda has completed a 90 day multidisciplinary surg...blah blah blah...She has been compliant with diet and exercise. She has improved her pulmonary reserve and lowered her risk for post-surgical complications. I recommend proceeding with weight loss surgery/" All that, along with psych, letter from family doc (medical clearance) and 2 year weight history must be there, or denial! Most people do not know about the 2nd letter from the surgeon. That is the only way it will fly! Most people are missing one of the letters. We actually send out 4 letters in our Aetna's pre-determinations from just our surgeon, the consult note letter, the letter asking for surgery, the pre-surg program letter and the after surg prep letter! Good luck! BONNIE

bonnied, I tried to contact you directly, but... You seem to know a lot about Aetna, so I was wondering, do you know in the case where WLS is excluded on the policy with Aetna, can they be convinced to cover it?  Do you have any experience with that?  It is not the employer's option that excludes it.  We are a smaller company with a "cookie cutter" poicy and WLS is excluded.  If they were faced with having to pay for one surgery vs. WLS, do you think they could be convinced?  My doctor is going to fight for me, but I was wondering what my chances are. Thanks, Sheryl

I have not met anyone in my practice that has won an exclusion, even the self funded plans in my area stick to their guns and do not allow WLS.  The only thing I have seen is some self-funded plans allow patients to bypass the required medically supervised diet, but they did have WLS coverage. Have you asked Gary for advice or looked at his site. He is super knowledgable. Depending on if your policy is self funded (meaning your employer pays for all the bills, not just pays a set amount to Aetna each month), you could have a chance. I have just not seen it. We have one local plan here, Cariten, that has an exclusion on 99% of their policies, yet their customer service reps tell the clients "send your stuff and we will review it". So the patients come into my office with false hope, thinking they have a chance, and they don't. It's so very sad to do that! I wish you all the best of luck. If you are excluded, you can still find a way to self pay. Money is very tight in my house and we managed to do it. Bonnie

Thanks, Bonnie.  Who is Gary? Sheryl

Gary  Viscio (might e spelled wrong!)is the laywer on this site, i believe it is www.obesitylaw.com, just look thru some of these posts, you will find him.

 I finally got approved!!!!!!!!  yay!  sooooo excited!