Aetna HMO - Sutter Medical Group

My insurance requires me to do either a 3 month or 6 month program.  I was told by my PCP that I needed to do the 6 month program because I have an HMO and the 3 month multi discliniary program doesn't apply to me.   I was also told that Sutter Medical group will not even approve my referral to the surgeon to get started on all the pre-op tests until the 6 months is up... does anyone have any experience with this?

If you get the clinical policy bulletin http://www.aetna.com/cpb/medical/data/100_199/0157.htmldo it does say that HMO's often exclude WLS. If yours covers it, I don't know why you couldn't do the 3 month regimen. I don't think that has anything to do with which you can do.

The best thing to do is to print it out and then go over it with your PCP.

I don't know anything about Sutter Medical group, but I didn't have to have a referral, so I can't speak about that part.

 Since you live in the wonderful state of CA and have the DMHC you do not have to do any pre op diet. I have provided a link to my thread on this topic. Go to t he DMHC's website and print out the peer review and bring it in to your PCP, also print out a couple of DMHC decisions where they've overturned insurance denial based on this criteria. Ask your PCP to submit for a consult with a bariatric surgeon, if he/she refuses call up your insurance and file a formal grievance. If they still deny you call up the DMHC and file an IMR and it will surely be overturned.  Best of luck. Neely



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