Question:
Anyone with Aetna PPO approved for RNY?!

Help... I am getting the run-around from my insurance carrier. I used to have Aetna HMO, I was denied, I appealed twice and was denied both times. Now I have Aetna PPO, I did all the crap they wanted, psych eval, blood work, EKG, chest x-ray and I have been on a medically supervised diet for the past 6 months. NOWwwwww they want a medically supervised diet with a nutritionist or dietician on staff with the doctor. I am so frustrated, annoyed, and worried. Is this going to keep happening? Are they going to change the rules again in another 6 months?! Please-anyone who has had surgery and has Aetna PPO, email me! I need some support and advice!    — Jeanne S. (posted on December 18, 2003)

December 17, 2003
Aetna has required the nutritionist/dietician (they do not have to be on staff with your PCP - I used one at my local YMCA and provided copies of her notes to my PCP to be added to my medical records)since at least January, 2003. Aetna also requires that an exercise regimen be established. Ask your PCP to "prescribe" exercise - even if it's just walking - and make sure they document it in your records. Here is a link to Aetna's requirements which can be found on their web site under "coverage policy bulletins". http://www.aetna.com/cpb/data/CPBA0157.html You have done most of what they require (Insurance doesn't require the EKG and Chest X-Ray - that's the Dr.'s requirement). Just try to schedule a visit with a nutritionist or dietician and get your PCP to document something about exercise in your records (make sure they document the nutritionist consultations) and make sure your medical records themselves go to AETNA - not just a letter from the Dr. I took care of my insurance approval on my own as I got tired of waiting for my surgeons office. I sent Aetna 7 years of medical records which showed my weight history, supervised diets, nutritionist visits, exercise regimen, plus all diagnosis (high blood pressure, pre-diabetic, etc.). Once they received this packet, I was approved in less than 2 weeks. I also included a letter in which I addressed each of their requirements individually and how I had met that requirement. If there's anything I can do to help - please feel free to e-mail me directly. Good Luck.
   — Carolyn M.

December 17, 2003
My advice to you is that you stay on Aetna until you get your approval. Many make the mistake of letting their PCP do all the leg work for them only to be disappointed by denial after denial. This is your life and your surgery. I called and called and wrote an appeal letter and called somemore. I think that the requirements have changed this year compared to the hoops I had to jump through. I didn't have to have a dietitian or documentation of exercise. Just keep on jumping until they approve you. They will but in their own sweet time. I know the hardest part is the waiting and you might think you will never be approved but I just know you will. TAKE CHARGE OF YOUR GOAL! You know what you want and with the help of this web site you will get all the answers you need to achieve that goal. Surgery 2-20-03 down 102. Best wishes!
   — Priscilla A.

December 18, 2003
I have Aetna ppo also and have been on the 6mo dr diet and went to a nutritional class...went to my dietian where I learned because I have diabetes..I hope I'm not going to get the run around like that..I've worked to hard...but of course they arent going to run me off...I'm going to do this untill they approve me...I wish you luck...i'll submit my paperwork end of Jan 04...
   — por2geegurl

December 18, 2003
Sorry to hear your having so many problems with Atena. My Lap RNY was 2/11/03 and I had Aetna PPO and was approved within 24 hrs of my letters being sent in. Of course, this was 10 months ago and things may have changed, since then. They were great! I had very high blood pressure and was seeing a foot specialist, besides my Dr. That seems like a lifetime ago. I now weigh 108 pounds less and have my health back. I went from a 24 to a 6, but the best thing is I have not taken 1 perscribed medication, since day of surgery. I exercise like crazy and feel better than I did at 20! I'm 54 years of age. I'm 4 weeks post op from Breast Reduction and loving it! I wish you the best and good luck!
   — Hazel S.

December 18, 2003
I'm not sure why they would deny you after all that. I was approved in 2 days and I BARELY made the morbidly obese range. The only thin I did was send a heart felt letter illustrating 'my day and the life of Adrienne' as an overweight woman. Must have clinched it for me. Anyway wishing much success.
   — corpdiva2006

December 18, 2003
Hi Jeanne, <P> I have AETNA PPO and was approved but only after jumping through all the hoops. I had already done the 6 month supervised diet, and I had a co-morbidity (diabetes) I just had to have physicians proof of 5 years of obesity. They are specific in what they want and as long as you give them everything they ask for, you shouldn't have any problems. <P> Don't make the mistake I made in counting on your surgeon's office to be sure they get everything. My doctor's insurance person lost a year's worth of records showing my diet history, so I was initally denied. Once I figured out what happened, I made sure to get copies of everything and stood at her desk while she faxed it all back to them. I was approved within 10 days.<P>It's definitely worth any and all trouble you might go through. I felt depressed and defeated when I got my denial, but I just marched right back into the fight and didn't give up until I was approved. <P>One last thing...don't be imtimidated by the insurance company..keep calling and bugging them until you talk to the person in charge of your file. Make yourself a real person for them and it's harder for them to ignore you. Just my opinion. <P>Open RNY 9-24-03 -43+ pounds
   — Tammyjo

December 19, 2003
I had the exact same problems with Cigna PPO. Did all of the above and after completing everything they initially asked for they started adding things to the list. Each time I would say "It would have been nice of you to tell me that four months ago!" Cigna (along with many other Health Insurance providers)hires Intracorp to determine medical eligibility based on their policies, see if this is the case with Aetna. Finally I had my PCP call Intracorp and ask to speak to a doctor on the medical review board, you know, the head honcho who makes the final decision, and right after that I was approved. Check it out & good luck!
   — boonikki29

December 23, 2003
I have Aetna PPO and just got approved on 12/18/03. I went in for one consultation with a dietician, and saw a psych one time for a consult. I got weighed and this charted on my Drs notes at least twice a month except for 1 month, and had appt with Dr monthly to discuss ongoing diet and excercise program. I started walking a little distance, and then progressed as time went on. I never did lose but 8 lbs, and then would gain and lose them again during the 6 mo period. Aetna says you can submit 3 mo into the 6 month diet for sugery, but DO NOT DO IT till after 6 months is up. I did, and they kept req additional info. I sent in for approval at 4 months. They req additional info at 5 months, which I sent in. They then denied, but I appealed after 6 months diet was up, and they finally approved me. Good Luck!! I would try calling to see if you can see a psych and nutritionist now, and possibly still get approved, since you've already been on the 6 mo diet. Were you discussing with PCP your excercise program when you went in monthly for weigh in? If you weren't excercising too, this could be why they denied. I am not cutting on you at all. I know the He!! of waiting and hoping insurance will approve you. I hope you get just the answers that you need to get approved soon. I will be praying for you. Prayer works. If GOD hadn't saved me from alcoholism, I wouldn't even be eligible to have this surgery today. I have a lot to be thankful for. Sorry for rambling. Becky P.S. E-mail if you need to talk with me further.
   — bufordslipstick