help with my letter

Hi All just wanted to ask on here if anyone has had any issues with revision and has Aetna -I saw my surgeon and he sent me to get a UGI series and also an EDG - well the results say my pouch is strecthed - this is what is says "gastric chamber measures 8.3 cm, transverse dimension 7.6 cm and 7.4 cm in maximum AP dimension-immediate emptying of the opacified stomach into the small intestine" The lady who handles the insurance first said all I will need is a letter from me, my pcp and the results and it should be sufficent - today she calls me and she says I "may" need a psch and nutrition evaluation - when I call the insurance they say they cant tell me what exact information I need to send only that the surgeon needs to open a claim and then they will tell me - but I dont want to just send this info and they they deny me - the CSR told me to go online and pull the bulletin and this is what is says     Repeat Bariatric Surgery:

Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction or stricture.Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:

1.      2.      Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure

Most insurences require Psych Eval just to know you understand the procedure you are getting into and they normally require PCP referal, UGI, EGD, and that it is medically nessisary. Every insurence is different but the Psych eval is nothing to worry about mine took 15 minutes and he said I am of sound mind and understand the procedure.  Good Luck.

Thank you MaryTeresa - I am not worried about the psch- just more worried of them asking for more info then what I have,,,,

when was your original surgery ??  I believe that aetna will also  cover revision if your 2 yrs out and have lost less than 50% of your excess weight.  When I applied for revision Dr Schlesinger wrote the letter and sent it , I followed up with  the underwriter and Talked to them  straight - told them where i was at .  Now as part of my  pre - surgery I need to have  a psych eval, chest exray, and ekg - but that is to protect  me , Dr Schlesinger and the ins company.  

my original surgery was 12/05 - I am looking online now for a "shrinky dink" like you said lol I have a nutritionist appt for next week - I am just upset with the insurance company - I don't want to submit the pshc/nutrit/ugi/edg results and then for them to say you also need 6 months of monitored diet...

The very best thing is to call and ask them  what the criteria is , get a copy and take it to your surgeons office ,  The Dr  will write the letter  and submit.  With revision is is not about  Supervised DIet if you fall into their criteria. You have already done that  by being eligable for the first surgery.  The Psych eval is more for the Dr  and Ins - they want to make sure you know what your getting into.  But counseling is a good thing - we all overeat for a reason - the sooner you find out  your reason the sooner you can address it and then there are some who never want to address the problem because they are too painfull ...  I dont think having  too much supporting documentation is a problem,  The nutritionist  is going to give you tips  to help, be prepared - they are going to want a food journal - Get busy now , write down every morsel of food you put in your mouth. the time of day and the emotion  at the time you ate it ..

I have a food journal all ready for my visit  - I am actaully online looking for a shrinky dinky close to my job - "The very best thing is to call and ask them  what the criteria is , get a copy and take it to your surgeons office" - that's the thing they wont tell me anything they just say to have my surgeon submit the claim and then they will tell him the criteria needed - I will try calling again - I clearly fit the criteria that they have on there - my issue is a mechanical - thanks for giving me your support

ok question - who is the insurance company ???

Aetna pos