Aetna ughhhhh HELP!!!

Hi all I am so frustrated with the pre-certification department for Aetna through my companies insurance. I am a nurse,so I get the needing everything in order quite honestly! I have done all my question asking to the benefit dept etc and have been advised from them to get my bypass done this year d/t all out of pocket and deductibles being met already ,so I have been going like mad fire to get everything in order. Surgeon,sleep study, letters of recommendation from all my current Dr.'s etc! You name it I got it and if I don't I can get it in 24 hours or less, this is exciting of course. You say then what's the problem? Well the surgeon asks about this medically supervised diet and I'm like a what so I call Aetna to confirm and they can't decide out of 4 calls what the rule is in regards to this criteria?? I ask for a copy of these criteria's and well you know it's against company policy so she then states I can go on Aetna's website and pull up the clinical bulletin and it's all there and basically says you can do the 6 month supervised or the 3 month Multi disciplinary surgical preparatory regimen. My questions after this long winded story are #1 has anyone been through this with Aetna and #2 is the surgeon/nutritionist/psychiatrist combo enough for the 3 months??? Thanks all for reading my long winded story.
Jen

I have Aetna as well and they directed me to the clinical bulletin. You need to read what the specific criteria is for the two different options. Your surgeons office should be able to help you as well since I am sure they have had other patients in the past that have had to meet Aetna's criteria. Hope you figure it out!

I have Aetna and myself and my three kids all had RNY and were approved though Aetna.  You do have to meet the criteria in the clinical bulletin 0157 or they will deny.  I had to appeal mine and my daughter's denial but we were approved after I appealed.  My two sons were approved with no problems but again, you have to do everything that is required in their criteria.

I sent you a PM of all of the information to help you with your approval!

Good Luck!

Nan

Thanks so much ladies!! My appointment with the surgeon,Nut and psychiatrist is tomorrow!! I am so nervous!!!

I’m hoping you can provide some insight. I have Aetna Select (Open Access). I am so confused on the multi-disciplinary program and every time I call Aetna for clarification, they tell me that are not allowed to tell me anything - that the pre-cert department makes those decisions. They will not put me through to the pre-cert department and tell me to have my surgeon call. My surgeon’s office called and they told me visits once/month for 3 months. Now I have read that some members were denied because their treatment was 87 days versus 90 days. Can you provide any clarification? Is it really once/month for 3 months or 90 days, and if it is 90 days, what date do I start counting from?

Sorry for the length of this but we plan to submit this during the 2nd week of October and I don't want to be denied because I'm short of 90 days if it is required. I also listed my appointment dates below. All of my labs and testing have been completed.

Thank you for any insight you can offer.

PCP

4/15/2013 (not weight related visit but did discuss it)

5/24/2013 (not weight related visit but did discuss it)

____ - no visit in June

07/17/2013 (not weight related visit but did discuss it and the decision to move forward with WLS)

08/15/2013 – visit 1

09/06/2013 – visit 2

10/4/2013 – visit 3 (next scheduled appointment)

Bariatric Surgeon

7/25/2013 – Seminar

7/29/2013 – initial appointment

10/9/2013 – Support group

NUT

8/20/2013 – group class

9/16/2013 – visit 2 (next scheduled appointment)

10/3/2013 – visit 3 (scheduled)

Psych

8/30/2013 – visit 1

9/5/2013 – visit 2

10/10/2013 – visit 3 (next scheduled appointment)

Physical Therapy

8/20/2013 – visit 1

_____ - visit 2 (have to schedule for September)

_____ - visit 3 (have to schedule for September)

It looks like you are doing all the right things, the only thing is you can't submit in early October or you will be denied.  Your first visit was really 8-15-13 so 90 days from there would be November 13th.  If you submit any earlier than that it will get denied.  That's what happened to me because my surgeon's office submitted too soon before I was finished with my appointments.  I spoke with someone at Aetna and they confirmed it has to be 90 days, no less.  I will send you a separate PM with everything I did and the letters I submitted with my approval. 

You will need to schedule a NUT and a PCP appointment for 11/13/2013 or after and then you can submit after that.

Once you read through the PM I am going to send you let me know if you have any questions!!

Nan

 

Thank you for clearing that up. It gets really confusing as my surgeon's office made it sound like I just needed 3 visits once/month. Ugh! I wish Aetna would make this easier and clearer.

Nan, how long was the turn around time for you to get the approval?

Sorry it took me so long, I just saw this post.  It takes between 15-30 days.  When my boys got approved it took 2 weeks.  Because my daughter and I were denied at first, the appeal took about 30 days for a decision.

I have Aetna (HMO not PPO) and it's been a 14 month journey.  Orientation, 6 months of weekly nutrition classes with weigh-ins, food and exercise diaries and a mandatory 10% body weight loss requirement, back to PCP for another referral for the pre-bari program, waited 3 mos for approval, then 2 months of weekly pre-bariatric education program with weigh-ins and diaries again, psych evaluation, back to my PCP for a surgical referral, then wait for approval and appointment to consult w/ the surgeon. That's where I am now.  The surgeon will tell me what pre-surgery tests he wants, wait for approvals, then VSG surgery hopefully in September/October (month 16). BMI started at 52 and now I'm at 43 and have to maintain or I'm cut from the program.

But, hey, at least they cover it!!!