Question:
New Requirement for Bariatric Surgery
Does anyone know of a new requirement by Aetna/US Healthcare QPOS that you have to have a history of failure of medical/dietary therapies documented by an attending physician who does not perform bariatric surgery? I was told by my surgeon that my BMI is 39 but I have enough co-morbidities to get approved. (Hypertenison, borderline diabetic, kneecaps wearing out) I was denied because I haven't tried enough dieting tricks. I was told that I cannot take diet medication because of my high blood pressure. What do I do? — Sherrie H. (posted on April 9, 2002)
April 9, 2002
I also have Aetna/US Healthcare. When I started the approval process last
October I luckily had a 3 year history of documented physician assisted
dieting programs/meds that hadn't worked and the lady at Aetna told me that
it was lucky that I had included that in my paperwork because that is part
of their requirement. But of course they don't tell you that before you
begin the process. I also included a list of EVERY diet program I had every
been on. My BMI was 41.
— Kathy J.
April 9, 2002
I don't think it's a *new* requirement. Many people have run into this,
especially at the appeals stage. They buy into the idea that diets work
and want to know you've spent YOUR money on a few and failed before they
pay upwards of $20,000 for what they consider to be a last resort. Some
people have had friends sign affidavits regarding their participation in
programs if the programs have lost their records. A lot of the programs
people have tried no longer exist or have moved around so much they've lost
paperwork. Read some profiles for tips on compiling a diet history. Try
to think of everything you've ever tried, including over-the-counter stuff
like Dexatrim. Good luck! :)
— PT LawMom
April 9, 2002
I had already heard I would need to list all the diets,pills shots
shakes,etc...that I had tried in losing weight.I had to prove i had done
these types of programs for at least the past 5 yrs.I did not have
documentation by a Doctor,but my surgeon took my word on everything I had
tried ,and he filed it with my insurance and they accepted it.For
example,xenical,diet pills,protein drinks,weight watchers,tops,diet clinics
etc.I think you get my drift.Think of everything you've used to try to lose
weight and present it to your surgeon.I hope I've helped in some way. LOL
,Lora
— Lora B.
February 11, 2003
You might want to check www.insure.com/health/obesity.html for some helpful
information on the new requirements.
— Barbara S.
March 5, 2003
Sherrie, I too have Atena POS and was approved. They did ask for a history
of diets before they approved me so I went back to my PCP and asked him
what we could do and he wrote me a letter stating that I tried several over
the counter diets as well as low cal diets that he believed didn't work for
me and that with my co-morbidities he felt that I'd be a perfect candidate
for gastric bypass. You can also go to atena's website and it gives you
their guidelines for approval. Their site is at www.atena.com and you can
choose the link from there! Hope it helps! Open RNY 8/20/02 -122 pounds!
— Carole M.
May 10, 2003
I am going through that right now. Was denied by AETNA even though I am
more than 200 lbs. overweight. I sent 2 letters of medical necessity AND a
list of diest I have been on, dates if the wieght loss, amount of wt.loss
and how long before I put it back on. I was still denied. Am appealing it
through an obesity law advocate, have also changed surgeons, and was going
to pay for it out-of pocket but AETNA would not pay should anything go
wrong, so that is NOT a good option. Meanwhile, I have started with a
nutrition but am mentally broken, trust me. Due to
"complications," my surgery date was initially changed four
times. And now, no surgery for a great while. I am a beaten woman. And
the kicker is, I will have to undergo those $8,000 worth of tests again if
I don't get my surgery soon as I had them in November/December. But, I'm
not giving up
— Margaret L.
May 13, 2003
It is such a shame you have to go through this. I had Aetna US Healthcare
pos managed choice went I had my surgery in March 2002. They did not ask
for ANY AND I MEAN ANY of this, but I included it in my paperwork anyway
that the doctor faxed over to them. Within ONE HOUR I was approved. I guess
something new has happened (at least that is what some are saying) since
Jan. 2003 that is making things more difficult for those needing this. Do
any and everything that they ask of you that is within your power, this is
too important to you. God bless you and good luck.
— gloriafb
May 13, 2003
Here is Aetna's published requirements:
www.aetnaushc.com/cpb/data/CPBA0157.html.
— [Deactivated Member]
June 10, 2003
They did ask for a history of diets before they approved me so I went back
to my PCP with a list and dates of diets I have tried over the last 2 years
so he wrote a letter to Aetna stating that I tried several diets as well as
over the counter products for diets that he believed didn't work for me and
that with my co-morbidities he felt that I'd be a perfect candidate for
gastric bypass.
Good luck.
Cindy
— clickrs
October 26, 2003
Oates
— Mikayla
October 26, 2003
Ok Im only being my journey with WLS. Ive heard such terrible things about
Aenta. Can some one show me an example of the appeals letter that you wrote
to send to them, after being denied the first time. I know I cant be one of
the lucky ones who get approved on the frist time. So I wont to have that
appeals letter ready for them.
— Mikayla
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