DENIED......HERE'S THE REASON!!!!
Earlier this week, I posted a request for help. Aetna/USHC denied me for laproscopic gastric bypass. At that time, I wasn't sure of why they denied me. I've later received their letter of explanation. It reads:
In order to complete our review and make a determination, additional information is required. Specifically, the following information is needed: Letter of medical necessity and either 2 years of progress notes documenting six months of physician supervised nutrition and exercise program or three months of multidisciplinary surgical program. They indicate that the info is needed to determine if my condition and requested service meet criteria outlined in Aetna's Clinical Policy Bulletin.
For the record, not only did I suppy them with a fully detailed letter of medical necessity from my primary care doctor, but also from every speciality doctor that I was required to see during this process. A letter of medical necessity was submitted with their official report. Furthermore, in regard to the request for progress notes, these records where supplied, as well. I was on a medically supervised diet from 05/96 through 04/98. I was one month shy of two years, however, the records reflect medical diet supervision for the entire time frame. Included in the progress notes was my recorded weight loss with each visit, blood pressure, diet medication dispursement and exercise regimen. I followed Aetna's guideline to the letter.
I'm not understanding what else I can possibly send these folks! I'm really wondering if they took out the time to review all the info that was submitted!
Any suggestion out there????
Did you go to the Aetna website and get a copy of CPB #0157? It spells out exactly what they want.
To sum it up:
They want a physician supervised diet and exercise regimen of at least 6 months duration, within the last 2 years with at least 3 months of it proximate to the time of surgery. They also want a certain number of visits with a nutritionist or dietician and behaviour modification. Did you give them all of this?
I also have Aetna and I had no problem getting approved. I was on a six month diet from March 04-Aug 04, I got a letter from my PCP saying I need the surgery, went to the nutr. once, psych. once, EKG and chest X-ray. I was approved in less than a week. I'm sorry your having a hard time. I thought I was gonna get put through hell with Aetna. Theres a yahoo group for only Aetna members trying to get approved for surgery, you might wanna check it out. Good Luck
Stephanie
Geraldine....
Sweetie I know exactly where you are coming from....I submitted everything to the T, to be approved under the guidelines of the multidisciplinary surgical program and they failed to even acknolwege that that pert of CPB 0157 sec 4B....I was allowed to resubmitt with additional progress noted from my MD...I sent this out Friday afternoon ...as of this morning there was still no news...but I was told to call back later in the afternoon...I am trying to stay positive!!!!
Good luck...
Christine
Christine:
Are you communicating with the facility located in King of Prussia, PA?
If so, can I have the phone number of whomever you've calling?
I contact member services and they told me that there was no number to call the approval department directly! (I knew this person was full of crap!) I was told that I could only respond in writing!
Thanks,
Gerri
Gerri....
I simply just called the number for pre cert ton the front of my card..I did not press anything and waited for a rep..I was directly placed in que for a pre cert rep...when they got on I explained and explained..until I got a rep who gave me the name and ex of my Case manager...then I called and left 100 messages with her until she finally said Re submitt...and then 2 days after resubmission I got my approval!!!!
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