Aetna help!!!!!!!!!!! Please!!!!!!!!!!

Okay I posted on the main message board but obviously I should have posted here too. Here's the deal in a quick nut shell. I was supposed to have wls this week but unfortunately aetna denied it. But with no medical basis. They beleive it is medically needed but weren't happy with my PCP's notes. They werent detailed enough. My PCP talked to him and went through my whole history. In turn the med director responded with thats great but Im still going to deny her. Real nice attitude!!! Any way when I started questioning things he changed his tune.He said he denied it because there was no recent documentation in the last two years of wl program.Well 9 mos out of the two years I was pregnant!!! Before that they put me on glucophage because I am insulin resistant due to pcos(poly cystic ovarian syndrome) After the birth of my daughter I went on south beach to no avail then to endocrinologist then back to low carb and exercise then to the bariatric surgeon. Im in the medical field so I understand how insurance companies can be. The general feel of things is that I do need to get an attorney to fight this.Because an appeal can take mos. Appreciate any input! Thanks! Lorie

Good luck and don't get discouraged!

I posted this to your second Aetna thread, but then realized that it was a reply to someone else's reply so you might not be notified it's there... anyway... Lorie, I know it really stinks to be forced into the 6-month diet. But that time does pass! I'm a week and a half away from finishing mine. I've used those six months to learn all I can about post-op life (thank goodness for OH!) and to attend multiple surgeon info sessions before selecting the one who suits me the best. Even if you plan to fight for approval using your current records, start a doctor-supervised diet NOW. Get to your PCP's office as soon as you can, do the first official weigh-in, and make certain that your doctor makes CLEAR, DETAILED, and LEGIBLE notes in your medical chart on what diet you will follow and what exercise you will do. "Patient is on a diet" and "Patient does regular exercise" is not enough; "Patient is on the following diet: 1200-1400 calories per day, no sugar or starches, 70g-90g protein daily" and "Patient walks 2 miles a day, 5 days a week" is much better. Have your PCP state your co-morbs (if any) in that day's medical record, even if they've been noted previously. Once a month, go back to the PCP's office to weigh in... and have your PCP include your diet and exercise information at every single visit, even if you haven't changed anything. If you see a nutritionist or join a gym or consult with a personal trainer, have your PCP note that in the record as well. Ask to see the actual notes on each visit to make sure everything is written down and readable. Give Aetna no excuses for denying you! (and yes, they have denied patients because the PCP notes were unreadable) FYI, Aetna has a second option, which is a 3-month multidisciplinary regimen that includes a nutritionist-supervised diet, a supervised exercise program, and a behavior modification program, all of which are supervised by your PCP. Some surgeons' pre-op programs qualify, or you could put it together yourself. The guidelines on Aetna's site aren't entirely helpful, though (they don't specify how many times you must see the dietician, psychiatrist, and personal trainer). Go to Yahoo Groups and join the one called AetnaWLS. There's terrific information available through the group about documenting to get approval. Some people have posted on how they did their 3-month multidisciplinary regimens - and got approved. Don't give up!