Question:
Is this enough to get approval?
This is what I have so far...I have met with my surgeon, sent a letter to AETNA 6 months ago basically begging for approval, faxed my diet history from 3rd grade on with my begging letter, listed all co-morbs, listed all medications to treat co-morbs, definitely meet all physical criteria w/ BMI, length of time as MO, co-morbs, met with phychologist, dietitian, upper GI dr, pulmonologist, PSP, internal medicine specialist,etc...I have updated my begging letter to include my new dr supervised diet and exercise program (diet since July with dietitian and since Oct. with surgeon)and have included a listing of every PCP visit where diet and exercise were documented/dictated. I am even preparing my letter of appeal 'just in case.' Is this enough to get approval????? — jenn2002 (posted on January 8, 2002)
January 7, 2002
It seems you have everything you need to be approved. I also have Aetna and
was denied the first time because I did not send the medical records for
the dr. supervised diets that I was on. Once Aetna received the information
they approved. Good luck!
— blank first name B.
January 8, 2002
Hi there,
I have Aetna Open PPO as well. I was 303 at 5'9", age 29, only
cormorbs are arthritis. My surgeon had you fill out a diet history form and
family history, etc. The surgeon's office sent the info to Aetna, and I was
approved in 6 days with no need for any other info to be sent to them.
Did they deny your first request? You mention that you sent it in 6 months
ago, surely you should have an answer by now one way or the other? Aetna is
one of the best in getting this surgery approved, so keep at it! GOod luck
to you!
— Tracie B.
January 8, 2002
By law your insurance company only has 30 days to look over your
pre-determination, and give you an answer. If you haven't gotten an answer
in 6 months you need to call the 800 number on the back of your card, speak
to a representative and ask them if they have any information in their
computer system saying they received a letter from you. Then explain that
your doctor sent in a predetermination letter to them 6 months ago, and you
still haven't gotten an answer. If it does not show that they received it
in their computer ask the representative you are speaking with if you (or
your doctor) if you can fax it directly to them. Have your doctor fax it
in right away. Since you sent it in 6 months ago ask the representative if
they will take it down to medical review personally as soon as they get it.
You should get an answer within the next 3 days because sometimes it takes
three days for the fax room to get the fax to them, but they should be able
to go get it that day. Then the nurses are supposed to look at it review
it then, and then give you an answer. If they refuse to do this, tell them
that they are required by law to do it.
I had a similar situation to this, and my insurance company approved me
that day. I have Cigna PPO, but the law is the same for each ins. co they
only have 30 days to decide approved or not approved.
Good luck!
and remember - Don't give up until you have that APPROVAL!
— [Anonymous]
January 8, 2002
I have Aetna also. I think 6 months is way too long!!! I am 5'7"
with a starting weight of 228. My BMI was 35, with sleep apnea being my
only comorbid. I only had 2 supervised diets...1 being Jenny Craig for
only 1 month and 2 being diet pills prescribed by my OB/GYN after my third
child was born. I only did the pills for 1 month also. After my surgeons
office faxed the documents I was approved in less than 24 hours. If I were
you, I would be a little more aggressive!!! Keep making phone calls.
Remember the old saying..."The squeaky wheel gets the grease"??!!
Well it is true. Fight for what you want. Good Luck!!
— skymaxjr
January 8, 2002
In my profile I have put a copy of my letter to my insurance company which
you might want to read -- it blew them away!! It even caused them to change
their policy on Laproscopic RNY! THAT blew me away! :) Otherwise, you
sound like you have it all together... good luck!!! (PS. Feel free to use
any part of my letter than you want!)
— Sharon H.
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