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I am told that the medical reviewer I got for my aproval/denial denies practically everything. So, when they seen that is who was reviewing my case they kinda knew it was already a denial. So, I did write a 2 page letter and sent it to the address I was given to who is looking over my case now. So frustrating-I started this process in March. I have everything documented 110% and did the steps to a T.
I am hoping it pays off with a approval. And soon! This is taking up alot of brain space right now for me!
Thanks for your reply,
Angie
I did Aetna's 3 month multidisciplinary program and so did my daughter. Both of us were denied at first. I filed appeals on each of our cases and was then approved. Did they give you a reason as to why you were denied??
I have copies of my appeal letters, etc but hopefully you will have found out by now if you've been approved or not. My approval after filing the appeal came after about 4 days. My daughters took longer - like 3 1/2 weeks.
Nan
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
Hi Marilee,
I was approved and so was my daughter on Aetna's 3 month multidisciplinary program. We were both denied at first, we appealed, and the decision was overturned. Both my son's are going thru the approval process right now.
When they say the presence of severe obesity that has persisted for at least the last years you do NOT need to have had moonthly weigh ins. Basically, you would need so show any doctor visits where your BMI was over 40 for at least 24 months and no where during that 24 months can your BMI have dropped below that or they will deny! So yes, you just need to show several years worth of physician visits where you were at a BMI of over 40 with no co-morbidies.
For the 3 month multi disciplinary program, it has to be 90 days span of time from your first visit with your pcp and the dietician. For myself and my daughter, we saw our pcp each month, and the dietician each month. Count out 90 days from the time you saw them and make sure your last appointment is at least 90 days past that. I was set up on an exercise program by a personal trainer, but I didn't not go to him regularly nor did my daughter. It does, however, have to be documented in your physician notes that you are participating in an exercise program such as wlking , weight training, swimming, etc and the frequency, etc.
Hope this answers your questions....feel free to PM me if you have more questions. I have samples of the letters we submitted for approval and also for our appeals. The behavior modification one is tricky...make sure your physician is documenting in the office notes your behavior modification, such as not drinking with meals, joining support groups (OH), eating small portions, eating protien first, etc.....
Good luck to you!
Nan
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
1) When they say, "For adults age 18 years or older, presence of severe obesity that has persisted for at least the last 2 years (24 months), defined as any of the following: " does that mean that we have to have MONTHLY weigh-ins that we can show or only that we were overweight at a physicians visit sometime during the year (we can actually show several years' worth of physician visits where we were overweight, but not a continuous, 24 months worth of weigh-ins;
2) I have heard people say that for the 3-month multidisciplinary program they only had to do visits with a nutritionist and the doctor and my daughter and I are starting on our third month seeing a nutritionist, the doctor, a person in his office (not quite sure what she does except talk to us about what changes we have made and what we are doing in terms of diet and exercise), and a psychologist to help us with behavior modification. Do we have to have three months of a supervised exercise program where we meet with a trainer or physical therapist? If we do, we will have to start the three months again and our insurance will run out at the end of December.
Also, the bulletin says that Aetna considers VSG medically-necessary when the criteria are met. Our insurance is actually SRC, an Aetna Company, and they do NOT do pre-certification. They define medically necessary as a procedure deemed necessary by a physician, etc. that falls under the accepted treatment for that illness, disease, etc. When I call them, I am told one thing one time and something else another. So, if we don't do something exactly right, I am afraid that they can deny payment.
So - does ANYONE know if we have to have 24 consecutive months of our weights or the doctor's say-so that we have had a BMI over 40 for 2 years and if we have to have supervised exercise sessions?
Thanks.
Marilee
1. Is there a weight loss exclusion on this policy?
2. If not, what type of Weight Loss surgery do you pay for? Some only pay for Gastric Bypass and Lap Band and not the Sleeve.
3. What are the requirements for Weight loss surgery? Usually it's a BMI above 40 with no bad obesity related diseases (which from looking at your ticker you should be above). Then some have you have so much of a documented medically managed diet and so many years as an obese person before they will cover surgery.
Best of luck to you!
-Carrie
My first dr supervised diet was from a hospital that included calorie restriction (800 primarily shakes) and weekly meetings with weigh ins, and planned goals for exercise. I have three letters from this dr/hospital diet program which was sent to my primary care physician outlining my attendance, goals, start and progress, and the letters span over/past a 6 month period, but I do not have my weekly weigh in logs. Silly me I threw out my weekly weigh in logs and I did this purpously because I had lost weight and never wanted to see these weight numbers again. Obviously I was not thinking of bariatric surgery at this time. Unfortunaltey it took me all but two years to gain back all the weight I had lost.
My second supervised diet was from my primary care physician PCP, and I have copies of pharmacy records that indicate I was on Adipex (diet pill) for 10 months. I did see my PCP various times throughout this process but not monthly. I also did Weigh****chers during this time but I have looked everywhere and I cannot find my weekly logs from WW. I do have documentation regarding my registration into two - 12 week WW programs but not my weekly logs.
What do you think? Will this suffice? What have others used for approval and or appeals?
Thanks.
Meg
Thanks
Mary
Hockeymom87 · 0 replies · 603 views
