Question:
Aetna said they required a 6 month diet.....but guess what?
I am so mad at Aetna POS. I work for UPS and Aetna denied the surgery because I needed a 6 month dr/dietician documented diet, along with a 5 year history of obseity. I did the 6 month diet and gathered all my previous health records for the 5 years. Now, they send me a notice that they are sending my appeal to United Parcel Post of America, because they don't approve the surgery. They only pay out the funds. I think I could have appealed to begin with and not done the 6 month diet. Has anyone else experienced this? — greg17 (posted on August 19, 2003)
August 19, 2003
Carol,
Hi, sorry for the prob's you are having. But I think I can explain it, I
dont condone it mind you, I just know what has happened, I THINK.
This is the explanation I got directly from the senior claims analyst at my
insurance company: The insurance merely company goes thru the
"packets" that are sent in either by the surgeon or the insured
themselves, they verify that all the criteia demanded by your insuranc co
to actually pay out are met. THEN the "packets/files" are sent to
a personal management company that consists of an MD and or nurses that
decide by the information given whether or not the required information
meets their specifications. FOR EXAMPLE: if they require 6 months of
dieting supervised by a physician, and although you have been to the doctor
& dieting with their supervision for 6 months, your weight was not
charted....you may be denied.
If they require that you have been 100 lbs overweight for 5 years....if
your chart shows yo yo weight dropping under that 100 lbs overweight they
can surely deny the pay out.
She said our job is only to make sure you have included the information,
the contracted company makes the decision based on the medical information
that you provide.
If this makes it more understandable, I am glad. I was livid, I got my
denial too, but I appealed immediately and was approved in 2 weeks. SO DONT
GIVE UP. Make them fight they just want you to give up so that they are off
the hook. DONT LET IT HAPPEN!!! APPEAL APPEAL APPEAL!!
THANKS & GOOD LUCK
— Leslie N.
August 19, 2003
Like the other poster said, not complying with the 6 month requirement
would have assured a denial from all parties. Now that you have met their
criteria, I think you stand a good chance of being approved, assuming it's
not a clear written exclusion. I assume if it was they would have told you
don't bother from the start. Keep up the hope as things could go your way
very soon.
— zoedogcbr
August 21, 2003
Hey buddy, I have UPS too here in Ky. I am a union ee and have Aetna also.
I know thru this website that you have to give insurance co's exactly what
they ask for before you will get approved. I started my required 6 mo diet
in May, but got busy and forgot to go in in June to have consult and weight
charted bi-weekly and just going in for weight checks every other week. I
have the WLS appt 10/23/03, but Aetna might make me wait till Dec to get
approved because of this. Oh well. I have waited over 2 yrs to get approved
so I guess I'll just have to go jump thru these last few hoops before I
finally get approved. (Take heart though, I have heard from others here
that Aetna is one of the best in giving approval for WLS). Aetna will cover
your dietician visit if you have sleep apnea or (I think) high b/p. I will
be seeing the dietician this Sat, and I have heard good things about her
from this website (someone critiqued her). Also Aetna will cover the Psych
(read NUT here), visit also. He was a nightmare (even though had good
reviews on here - threatened to not give appreoval letter unless you went
to his support meetings ect... - but this is another story. I just want to
have all my ducks in a row, so they will possible approve me ASAP! Good
Luck!! I always wondered if there were other UPSER's out there using this
site and trying to save their lives.
— bufordslipstick
August 21, 2003
P.S. I forgot to put that I have Aetna PPO. Hope this info helps!!
— bufordslipstick
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