Question:
I just found out from my surgeon that Aetna HMO
requires a 6-month doctor supervised diet program prior to authorizing surgery. I am so upset about this. I have been on every diet known to man including attending the Hospital's diebetic training classes. To no avail. Has anyone else had to deal with this. My PCP is not totally convinced the WLS is the best way to go, so I am sure he will make me go to weight watchers or something (already been there and done that). Any suggestions!!! — pazazztapper (posted on October 15, 2003)
October 15, 2003
My PCP actually surprised me... they were not (the group of Dr's) so
supportive of the idea, but knowing it's what I wanted they went with it...
I didn't have a six month persea w/ these Dr's as i had just moved to town,
but we went over my diet history and they wrote up a great referrel, and i
was approved in no time (it seemed like forever then)... but I went to my
seminar about the surgery on May 21st and had surgery July 18th...that's
not too bad. I had to really keep up on NewStart and getting insurance to
go through... I called once or twice a week, and stayed on top of things. I
say go ahead and start that 6 month supervised diet, and also talk w/ your
PCP you may be able to get documentation that you have tried these other
things. I had done weight watchers, slim fast...you name it... all of those
were mentioned in the referrel...
— MF
October 15, 2003
This has been one part of Aetna's requirement since 1/10/03. They have
recently made some changes, but that isn't one of them. You can go to
their website and look at the bulletins
(http://www.aetna.com/cpb/data/CPBA0157.html)
I have Aetna and I was denied until I met their diet/nutritionist, exercise
requirements (they now require a psych evaluation also). It is not up to
your Dr. to decide whether you have to do WW or some other program in order
to qualify - it is Aetna's requirement and there isn't anything that he can
put in a letter that will change that. If you choose WW, you will have to
send a copy of your weigh-ins and your PCP will have to provide a copy of
your medical records (summary letters are not accepted) showing your
weigh-ins in his/her office as well as documented visits with a
nutritionist/dietician (also noted in your PCP's medical records) as well
as an exercise program (again - noted in PCP's notes). As soon as I was
able to provide their required information, I was approved within 10 days.
Also, instead of trying to find a way around the requirements, you'll be
better off in the long run just abiding by them. They're not that out of
line (some insurances require 2 - 26 week supervised diets) and you'll
spend more time and money than you would if you just had your PCP put you
on a low fat or low cal diet. It doesn't have to be Weight Watchers or
some other chain diet as long as he puts in your records that he is putting
you on a diet and you go in monthly and get weighed.
Feel free to e-mail me directly if you'd like.
Good Luck.
— Carolyn M.
October 15, 2003
It took a week for Aetna HMO Patriot V to approve me! In fact, I just got
my approval TODAY! I didn't have a specific 6 month medically supervised
weight loss history however; my PCP have been with me for the past 7 years
and documents EVERY visit to the letter. Due to my hypertension for the
past 10 years and my more recent diagnosis of type II diabetes, I've been
visiting him every 3-4 months for blood pressure checks, weigh-ins and
bloodwork. My weight loss surgeon just faxed five years of my medical
chart to AETNA and I they approved me. Don't be intimidated and don't give
up. There is a way and a solution!
— Cheryl G N.
October 15, 2003
When I had my WLS (a two and a half years ago) I had Aetna HMO program and
was approved without a 6 month diet program. I had recently read that many
insurance programs are now scaling back on the WLS approvals because somany
people are wanting them and it is costing them too much money. While you
and I both know that the long term cost of obesity is probably larger than
this surgery, the insurance companies basically do not care about long
term. They care about now...today. Their only responsibility is to their
shareholders who also only care about this year's earning. not the
earnings ten years from now. They way insurance companies feel is thatthey
are not in the business of kepping us healthy. That is not their business.
They are in a profit motivated business and will do what they have to to
keep expenditures down. Even if they can delay paying for your surgery for
6 months. They hope that maybe in 6 months, you will have changed your
mind.
— Melissa C.
October 15, 2003
Rita,
Here is the entire Aetna HOM requirment document:
http://www.aetna.com/cpb/data/CPBA0157.html
— Tom Barton
October 15, 2003
I too have Aetna ppo and have started my journey of insurnaces and found
out that I have to have the dr 6mo diet and started it right away instead
of wasting time..thier getting stricter on these things...some they have
channged for the better, I check just about everyday on the Aetna website
for changes which happen everday and there has been atleast 3 changes on
#157 Obesity surgery since Jan 10th 2003 so keep up with the changes they
give..and print them out..I do and keep logs on who you chat with at the
Insruance co. good luck and keep up posted..my 6mo is up in Jan 04 then I'm
done and ready to apply.
— por2geegurl
October 16, 2003
Aetna isnt the only insurance company that requires this. I have Health
America and they also require a supervised diet however its only 3 months
at this point. They also require a psych eval and nutrion eval. I know how
you feel and agree its crazy to have to go through yet another diet when
most of us have dieted most if not all of our lives. If the diets worked
for us... we wouldn't be here now and wanting the surgery.
— Christine S.
October 16, 2003
Hi Rita,
This is not new for Aetna! It may be new for your policy but I had surgery
2 1/2 yrs ago and had to have 2 medically supervised diets then. Weight
watchers etc...was not considered medically supervised. You need to
physically go to a physician or a nutritionist w/in a physicians practice
to qualify. Yes, it's frustrating but I have to tell you the stupidist diet
I had ever been on was a medically supervised one! Hang in there and you
can do this. Yes, 6 mos. seems like forever but it isn't. Use this time to
learn to change your eating habits. You will need that once you have
surgery. Unfortunately you need to play the game.
Best wishes
Linda Mickel
P.S. Does your plan cover payment of nutritionist? My husbands contract was
just renegotiated and they now have nutritional counseling for obesity
covered!
— Linda M.
October 18, 2003
You know it really saddens me to see what is being required for the
morbidly obese now through Aetna and other insurance companies. When I
appled through Aetna in 2/02 it took a few HOURS, you read right, HOURS for
me to be approved. I did not have to have any medically supervised
anything. My surgeons office did fax them a letter stating how long I had
been obese and the medications I was on for obesity (Xenical and Meridia)
they called him a few hours later and said APPROVED. Thank god they were
more compassionate and less greedy back then. Since Jan of 03 all hell has
broke lose with this, as one poster mentioned probably because so many
people are wanting to have the surgery and it is expensive. However, in the
20 months since I had surgery I have already saved my insurance company
thousands. I use to be hospitalized almost monthly for my diabetes, which I
no longer have. I use to stay in the hospital anywhere from a few hours to
a month. The one time I was in the hospital for the month the total bill
was almost 65 grand....my surgery alone was only 25 grand. I haven't been
hospitalized once since having this surgery and I only go to the dr's
office to have my labs checked every 4 months just to confirm what I
already know and feel, I am the picture perfect of health. My prayers are
with you and everyone else who is being put through this nonsense.
— gloriafb
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