Super Freaked out and nervous!

Hello all.

Now that I have read the stories about people with complications with Aetna approving the surgery I am super discouraged.

I am working so hard on the presurgical 12 week program (week 6 of 12 so far) and I am spending so much money, it makes me sick to think that I could get denied.

Is it really worth it?

 I GOT APPROVED  BY AENTA IN A DAY   SO YES IS WORTH IT   DONT THINK NEGATIVE  THINK POSITIVE

It is TOTALLY worth it.  I was denied for surgery because my surgeon's office submitted my paperwork to soon.  I too was doing their 3 month multidisciplinary program.  My surgeon's office submited the paperwork thinking I had completed it with my PCP.  I had not and was denied.  I finished the 3 month MD program, appealed, and won.  I had surgery in March 09 and have lost 160 lbs.

A friend of mine was denied by Aetna also.  Reason being 'lack of proof of obesity for 2 years'.  I helped her with her appeal and she was approved and had surgery in Jan 2010.

My daughter was also denied.  I appealed for her, and she won!  Had surgery this past May and is down 78.5 pounds.

So yes, it can be quite discouraging to hear all the stories of how Aetna is so hard to get approved, but basically, if you meet all of their requirements in their clinical bulletin 0157 (I'm assuming you have that already) you will get approved.  You just have to make sure all of your T's are crossed and your I's are dotted!  And if you are denied, get the reason why, and prove to them what they need to see.

One thing to keep in mind, it is not a 12 week program according to one of the Aetna appeals team member's I talked to.  It is a 90 day multidisciplinary program.  The wording when I was getting approved said 3 month multidisciplinary program.  He said this means 90 days!!  No less or you will get denied.  So make sure your first appoint and your last appointment with your PCP are at least 90 days apart!

I will PM you if you'd like a breakdown of everything I did to get approved.  Also, when talking to the Aetna representative, they stated the importance of the 'behavior modification' and that being documented with your PCP.  So make sure you are meeting all of the requirments as stated in the 0157 bulletin.

Good Luck to you!

Nan

Thanks for the information. It is 90 days, and it is done in the sugeons office through their "medical weightloss clinic" that is monitored by an MD. I have weekly classes and weigh ins that include every other week classes with the nutritionist and behaviorist (behavior modification).

Do you think it is wise to get records from my primary care doc that I have noting my weight from the past 2 years or do you think the MD from the 90 day program will get it for me?

Also do you think it makes a difference since my insurance is backed by the Teamsters Union? 

I appreciate your help!

It sounds like you have everything under control!  I would definitely check with the MD from the 90 day program and ask if they are requesting your past 2 years medical records because you will need to submit them with your paperwork in order to get an approval by Aetna.  And make sure your BMI did not drop below 40 in that 2 year history !  They will deny for this also.  (or BMI of "35-39.9 with co-morbidies. 

But yes, definitely get your medical records to whomever is going to submit for approval.  Not sure if the MD from the 90 day program automatically does that or if it's something you have to initiate.  Sounds like they have a good program in place though for meeting the requirements!

Oh yeah, even at my lowest with my PCP my BMI was still over 40. I will keep everyone posted on how it goes.

It is, but I need you all to remind me too (Nan, I PMd you). 

I'm trying to have a DS at GHP, but I live in Indiana and Grand Rapids is a three hour trip each way, so their 90 day/weekly program is not an option for me, and they told me today that if I can't do their 90 day program I have to do the six months. 

Tomorrow I'll get back on the horse.  Tonight I am angry and sad.