help

I have Atena PPO. I tend to over think and over analyze alot. For some reason..i just know I'll be the one who gets a insurance denial. With that being said, I started seeing a lap band doctor in Dec of 09. He said he felt i would do better with the roux en y, but would give me time to make a choice. I did my pulmonary testing, all my labs, my psychological eval and everything. He put me on medifast and i even lost a few pounds doing that. After doing my research i decided that i would benefit more with the bypass instead of the band. He referred me to another surgeon because he only does banding. I met with the nursing staff there and they tell me that with my insurance( Aetna PPO) i have to be on a 6 month diet and nutrition program. I knew about the nutrition part and i was doing that with the band doctor, but i had no idea about the supervised exercise program. My doctor never said anything about it to me...and here i am almost 5 months into my "6 months" and I'm feeling like I'll probably get a denial because i have no "supervised" exercise documented. My band doctor told me everything would transfer with me...and that i wouldn't have to start my 6 months over but now I'm feeling like i may get denied.  This process is so emotional.Ii already have days where i just wanna break out into tears because i feel so overwhelmed. anyone have any suggestions???

You are right this process is very emotional.  I really understand what you are going through.  That very same thing happened to me on January 26, 2010.  I was devestated!  I was already 5 months into my program when they hit me with the diet/exercise mess.  Absolutely no one told me about the diet/exercise.  I actually found it out on my own by calling my carrier and going online. 

Start now with weigh****chers or simply making documented weight & exercise visits with your primary doctor.  Because I did this, my insurance carrier accepted both documentations.  You only have to do one or the other.  It's cheaper to do it with your primary doctor.  If you contact your primary doctor ask them to check your records if they have documented visits of weight you can use that, but I don't know if they have to be documented consecutively for six months.  It won't hurt to ask, trust me.

There really aren't any words that I can say to help with what you may be feeling, but I will say don't give up you will get thru and your six months will fly by if you end up doing the exercise program.  I did have a change in my situation and I ended up not having to do the six month stuff and got a surgery date.  God works in mysterious ways, you just never know what's going to happen if your heart is in the right place.  Keep your head up and good luck.

Shontel

Did you visit you PCP in the last six months? Are you close with him/her? Ask if they can write a letter documenting your weight loss.

Hi,

I have Aetna also and you do not need a 'supervised' exercise program.  They have two types of programs you can follow.  The 6 month physician supervised diet or the 3 month multi-disciplinary program.  With the 6 month program, you need to just make sure that it is a physician supervised diet and they are documenting your weight, height, bmi, eating and exercise activity in thier office visit notes.  The 3 month mulit disciplinary program is a bit tougher to meet the requirments because you have to do the physician supervised diet, alont with a consultation with a dietician or nutritionist, and document your exercise and behavior modification. 

I would say keep doing what you are doing.  You need 6 months of documented visits with your physician.  That would mean 7 visits total because the first one was the start of your program.  Make sure they are documenting each time that you are being seen for weight loss and documenting everything in your chart so that you have it for Aetna when you submit for approval.

Hope this helps. 

Thanks everyone for ur responses.

Nan..my surgery center "was" doing my supervised diet. Now that ive switched..i dont kno what is going to happen. Thanks this really helped alot.

Just don't give up!  I was denied at first, appealed and then was approved.  My daughter is going through the process right now, was denied on March 9th and we filed her appeal on the 12th - still waiting for the final decision!!!  I know it's frustrating, but if you print Aetna's clinical bulletin 0157 (I have a copy), it states their requirements.  As long as you meet those requirements you should be able to ge approved.  You may have to appeal, but it is worth it in the end.

Can you have the surgeon's office you were working with send your records to your new surgeon's office? 

Good luck!

Nan