I need help with Aetna

I have Aetna Managed Choice POS. My BMI is 42 I have GERD, documented sleep apnea, glucose intolerance, back pain, hyperlipidemia. I was denied coverage yesterday because my PCP hadn't documented enough in her records. She called the Aetna Medical Director and he suggested that she "fix" her records! She is ethical and refused to do it, so basically he called her a bad doctor for not charting more and said start over for 6 mos then try again. He also told her that me going to Weigh****cher's on my own was not the same as her telling me to. I am so disappointed. Anyone have ideas for appealing???

What does your plan state regarding a diet history, if anything? It is my understanding that Aetna is requiring a 3 month diet, and that info is published on their website. Of course, I could have been misinformed, and I haven't had the need to check this out myself. As far as your PCP's documentation, she needs to stand firm and write in her letter that she documents her charts to care for her patients needs, and not the discretion of insurance company bureaucrats. Few physicians write down every single word spoken during an exam. I would never suggest anything that could be construed as insurance fraud, but there is nothing wrong with her writing a narrative of her discussions on weight loss with you based on her memory of the event.

Roberta, Thanks so much for your reply--I have been so busy with my appeal package that I didn't get a chance to write back. Aetna is requiring a 6-mo "physician supervised" diet or a 3 month "surgical preparation program" that includes PCP visits, exercise regimen and documentation (i.e., from a health club or trainer), psychologist provided behavior modification, and dietician consultation and following I put together a package (with many of your pieces of advice from this message board--thanks!) that includes a detailed, fact by fact letter and a binder with 40 Appendices including letters from PCP, sleep apnea doctor, weigh****cher's payment receipts, personal fitness plan from my gym, my photographs (yikes--so painful to look at!!!) of me and also with my CPAP headgear. I included multiple scientific references and put the abstracts into the appendices as well. In addition, I disputed their "physician supervised" bit by both stating that I should not be penalized because of absence of charting in my PCPs notes, and also the fact that I am a nurse and now work for a pharmaceutical company doing research. My last project included developing patient education materials on diet and activity for a diabetes drug--I laid it on thick about my expertise. Keep your fingers crossed for me. I'll post again when I hear from them--sent the package out overnight mail today. In the meantime, I am making another appt with my PCP to get the referrals for the 3 month program to get started in case this falls through. I am determined!!! Krista

I have BCBSAL and they have changed their criteria close to what your Aetna policy says. I was denied last Jan because my BMI hadn't been >40 for two consecutive years (duh...all those dieting efforts, then regains). It has been >38 for five years with several comorbids (apnea was determined not significant enough to qualify). I got busy with life in general and missed my deadline to appeal so here I am a year later ready to start the whole process over (this time going for LapBand, which IS covered by my policy). I am starting my six month weight loss program today (Weigh****chers) and already have an appt with my GP to document that I am starting a weight loss program. I will be dotting my i's and crossing my t's this go around. Not to mention, I have added two new comorbids to the list, one of those being hypertension. According to the criteria they mailed me, once I complete the six month required weight loss program, assuming I still have a BMI of at least 36 (I will definitely), I should qualify. SC

I need help also or some idea on how to write the letter my insurance want my PCP to write a letter about a six months diet and he asked me to write it.