Question:
I have 1 more month to go on the 6 month Aetna required doc supervised diet.
Aetna denied the surgery in Feb because I didn't have a 6 month doc/dietician diet program documented. I now have 1 month left on the "diet". Should I be contacting my surgeon now? Should I just wait until I complete the 6 month program? What should I be doing now? — greg17 (posted on July 10, 2003)
July 10, 2003
Once your six months is up, write a letter to your insurance company (use
the address from the denial letter) saying that you have now completed the
required six-months of monitored dieting, and to now please reopen the
request for approval - and send them copies of your medical documentation.
Then, call them in a week or so to make sure they received the info, and to
check on what they're doing about it. Once you are approved, call your
surgeon for a date!
— bethybb
July 11, 2003
I had scheduled a consultation with my surgeon back (phone call in 6/03),
and since he is so booked, the appointment is not until January, 2004.
LUCKILY, his staff warned me of Cigna's 6-month required Dr. supervised WL
requirement during my first phone call. So, I can do the 6 months
"diet" and then get right in to see the surgeon. ***I would
suggest calling your surgeon's office, and setting up an appointment that
will be just after your 6 months are done*** It will take a few weeks at
least to get you into surgery, and you will have hopefully met all the ins
requirements then and be approved...if not, all the surgeon has to do is
bump your surgery date back while they wait for your approval. Just my
thoughts... GOOD LUCK!!!
— Susan B.
August 26, 2003
Now that I have fully met their requirements. They are saying the my
participation in the program was insufficient. My employer has agreed, thus
upholding the decline.
So I am being advised to try again next year. I have decided that they
could try the same thing next year and my fight would be that much more
difficult. They, my employer and Aetna, have not given me any guidelines
for what is acceptable, only that what I have done thus far is not
acceptable. I am challenging this crap on the grounds that they never
provided me with any guidelines of what was an acceptable physician
supervised program and/or what level of participation was expected. My
program consist of an endocrinologist, surgeon, nutrional nurse educator
and the use of an exercise physiologist post-operatively. Although, I don't
think it would be a problem to see them before hand. I just have chosen not
to. I joined a gym and utilize the instructions provided to me by my nurse
educator/nutritionist for my exercise plan.
This is unbelievable. I qualify and then they come along with some unknown
criteria to determine my eligibility. I AM GOING TO REPRESENT MYSELF IN
COURT SINCE I CAN NOT AFFORD AN ATTORNEY. WISH ME LUCK!!!
Felicia Underdue
— aflower1
August 26, 2003
I was recently denied and then approved by Aetna because of their new
guidelines. My initial request and denial was because my surgeon's office
didn't include all my records (they "lost" them somewhere in the
office). This is what was included in my appeal:<P>
All the records from my current PCP from 2/2001 when I started seeing him.
His transcipts from my visits are what sealed the deal for me, I'm sure. In
his notes he included my weight, if I had gained or lost since the last
visit, what food issues I was having, if I was exercising, when and how
much, what I was doing to control my diabetes, my attitude toward my
gains/losses and general comments about my support system and how I was
feeling. He is an incredible doctor and I am very blessed to have him. I
know that if his notes hadn't been so good, they might have denied me
again. My previous doctor's notes were horrendous and if I didn't have to
prove the 5 year history of obesity, I would never have included them. I
saw the man for 7 years and when I requested my whole file, his office sent
about 5 pages of notes, front and back. My 5 year old niece could have
done a better job. <P> I said all that to say this: in my
experience with Aetna, I feel like my doctors notes made all the
difference. Make sure your doctor has documented all your visits, weight
gains/losses and discussions about food and exercise. When I was getting
my appeal ready, I talked to my caseworker and asked her for specifics
about what they really wanted to see. She said they want details. If you
have charts of your weight loss from the doctor or dietician visits,
include those. Just flood them with information. I sent old and new PCP
files, pictures of me throughout my life, proof of my membership in a
women's fitness center, and a long and detailed appeal letter. (Let me know
if you think it would help you and I'll email it to you) After receiving
everything, they had to answer me within 15 days and I was approved.
<P> I wish you the best, just don't give up.
— Tammyjo
March 18, 2004
I have run into this and this is what I found out. This is through
(obesitylaw.com) and the lawyer is Walter Lindstrom. with the research
they technically cannot require you to do something that they exclude from
paying for in order to qualitfy for treatment. It's called basic plain and
simple discrimination.The lawyer can cost as low as 300.00 for their help.
You need to go to that site. Best of Luck!!
— Cindy L.
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