Question:
My 19 year old daughter was denied with a BMI of
45, she has the long history of obesity and several stints with Weight Watcher etc (which was provided) with the original insurance information. The insurance co. is Aetna and they do cover the surgery, but she was denied because of no 6 month Doctor assisted weight loss program within the past last two years. — Paul M. (posted on February 24, 2003)
February 24, 2003
Aetna does bend some on that if you have 3 months then alot of times you
can still get approval if she has none get her to the doctor to start one
then when she has atleast 3 months try for approval again. They are getting
tighter on there approvals. I was approved by Aetna PPO the first try with
only three months supervised. Good luck. Alicia
— Alicia K.
February 24, 2003
I would suggest an appeal and while waiting maybve get on a Dr supervised
diet in the meantime. Jamie
— Jamie M.
February 24, 2003
Hi, Paul. I also have Aetna PPO and got some static when my doctor's
office sent in my request. They wanted 5 years worth of diet history.
However, I went to my initial consultation with a three-paged letter
explaining my life-long struggle with obesity. I had a letter from my
cardiologist in my file that said I had been unsuccessful for a long time
(no specific period)at losing weight. I asked the insurance girl at the
doctor's office to re-fax those two letters on the off-chance that the
person making the decision didn't get them. About a week later I got my
approval call. This was a dream come true for me because I had fought with
the Oklahoma State Insurance Office for fours years to get approved. I
switched jobs and was approved in two months with Aetna. It was an
answered prayer. I think Aetna is one of the easiest insurance companies
to give their approval, based on my experience and a lot of reading on this
website. God bless you both. Kristi Kear/VBG 6/7/2002 down 80 pounds.
— KRISTI K.
February 24, 2003
I don't want to be the bearer of bad news, but those who have posted and
said they got an approval based on their doctors letters or their own
documented history are fortunate that they attempted this before 1/1/03.
This is when the requirements changed. Aetna will no longer accept a
doctors letter or a patients records for the diet history. The 6 month
diet must be noted in the medical records themselves. I know. I also have
Aetna and am currently going through the same thing. Weight watchers
doesn't count because the don't have a dr. or nutritionist supervising the
diet.
My best advice would be to have her doctor put her on a diet for the
required 6 months and make sure he documents everything. Also request a
referral to a nutritionist.
Good Luck
— Carolyn M.
February 24, 2003
Knowing how busy surgeon's offices are and how long it took me to get
through everything, it might be 6 months before she could have surgery
anyway (or a year or more...). Get on the diet while appealing.
— Toni C.
February 24, 2003
Just a follow-up question, as my best friend also has Aetna and was denied
for the same reason- no specifice documented weight loss plans, although
she was on Merida and Zenical for a combined year last year. BMI of 52 and
SEVERE Co-Morbidities.
We live in Maryland, where the insurers are mandated by the state to pay
for this surgery as long as there is no specific exclusion and it is not
small group. She has no exclusions, and is part of an enormous group. How
can they deny this surgery? Does anyone know?? Should we go to the
insurance commissioner or appeal? Thanks for any help you may be able to
give. Aetna's change in criteria has affected many, many people on this
board.
— Leslie M.
February 25, 2003
Hi Paul,
I have Aetna PPO. I was denied on my first attempt. I then appealed
sending them:
1) A letter from my current doctor
2) A letter from my old doctor
3) A letter from the surgeon
4)*A letter from my best friend.
5)*A letter from me
6)*PICTURES (gather pics throughout her 19 yrs)
(*these are personal and lets them see you as a person not just everyday
paper work.)
Please contact me so that I may explain more in detail.
Good Luck!
— Dayanara A.
February 25, 2003
I'm sorry she was denied, but appeal appeal appeal! I have AETNA PPO and am
23 (was 22 for surgery) I fortunately got approved on the first try, but I
have heard that AETNAs requirements have changed this year. As far as I
know however, you were always supposed to have doctor-supervised diet, even
when I got approved. I never did, htough. Did your PCP write a letter tot
he insurance? I think that helped me alot, my doctor wrote a letter stating
medical necessity, and that I was under his care during the times I did WW,
Atkins, LA Weight Loss, Lucile Roberts and other diets and gyms. So maybe
you can try that? Goodluck to you and your daughter!
— Lezlie Y.
February 26, 2003
I know I'll get killed from everybody for saying this but isn't 19 to
young???what kind of history can she have? sure she has been overweight I'm
sure but was she ever on a good program where she exercised?....
I was what I thought was overweight when I was 19....but to make this
choice so young I just don't think it's the answer at such a young age.
— c T.
February 27, 2003
TRUST ME...you can have a diet history at age 19. I am 21 and had surgery
in Aug. I have been dieting since I was 10 years old. Fad diets, weight
watchers, jenny craig...everything. I hope everything works out for your
daughter. Good luck!
— fropunka
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