Question:
How can I get AETNA approve surgery.
I have been denied twice. I am 100 lbs and more over weight. I have swelling in my legs and I am on HCT meds. I do take previcid. I have been on meds for insilin residence and I have been gaining more weight. I have many bouts with depression and on meds for that as well. AETNA says they want my PCP to oversee 6 months of diet and behavior modification before they will approve any surgery. Has anyone had this situation with AETNA. By the way I have a PPO. This has been very trying and has sent me into another two months of depression. — jean B. (posted on March 18, 2003)
March 18, 2003
If the only reason Aetna is denying you is that they want 6 months of
doctor supervised weight loss, go to your PCP as soon as you can and have
him/her put you on a diet. I know this is not what you want to hear, but
you say you have had two months of depression about this. If you had gone
to your PCP when you first got denied, you would only have four months to
go. It will be a lot easier to just comply with that than it will be to
try to fight it. During those 6 months you can pick a surgeon, find out
what other requirements Aetna has and comply with those, find out what
other tests the surgeon may require so you can get those scheduled, etc.
I'm sure your policy doesn't say that you actually have to lose a
significant amount of weight. I'm not saying you shouldn't try to, but the
sooner you go to your PCP, the sooner those 6 months will be up. Make sure
that your PCP puts it into your chart that you are being told to lose
weight. Find out how often Aetna wants you to go to get weighed. You
should probably have your PCP give you a referral to a dietician. Go to
one and have that person report back to your doctor (and make sure that is
in your medical records) what you were told during that visit, etc. The
six months will be up before your know it.
— garw
March 18, 2003
Here is another perspective: I won't even get my first consult with the
surgeon until mid-October, 7 months away. So your six months of diet and
behavior mod is still less than I'm waiting just for an appointment. During
that time I will try the Atkins diet, under my PCP's supervision. That way,
maybe I'll have lost some weight, and I'll have a recent diet history. Good
luck.
— Kasey
March 18, 2003
I have Aetna and was recently approved. I was told I was going to be denied
due to the 6 month provision. I immediately went to my PCP and had him put
me on a supervised diet with a dietician.(sp?) I then had my surgeon
resubmit my approvall request and behold 3 weeks later I was approved. So
hang in there and start your diet, remember it will be your last. I know
you don't want to begin another diet but you must do what they want. They
hold the key to your success. Best of Luck.
— Barbara S.
March 18, 2003
I have Aetna PPO and called them and was told that even though you have
documentation of past weight loss Aetna now requires you to have 6 months
of physician supervised diet with a nutritionist. There is no way around
it. This is what I am going through right now. I had my consult in February
and now am going through the 6 month thing. We just have to hang in there.
Good luck.
— Dawn M.
March 18, 2003
I'm in the same situation as you. As soon as I found this out, I asked my
PCP about it. He originally thought he could take care of it, but instead
of waiting on him (just in case he couldn't), I took it upon myself to find
a dietician since the one he wanted to refer me to was an hour drive away.
I found a registered dietician at my local YMCA where I am a member. My
PCP was actually very interested in this and plans to refer others to her
since they have a hard time finding a reasonably priced ($40.00 first visit
- 1 hour and $20 for subsequent visits - 1/2 hour)dietician because most
insurances (including Aetna) will not normally cover these costs. As for
the behavior modification, I'm not sure if the dietician covers that
aspect. I'm in the process of getting a psychiatric consult (secondary
insurance requires it anyway) to see if I can cover the behavior
modification requirement.
Once you get a couple dietician visits in and get your PCP to note it in
your chart that you are doing this, I would re-submit and see what happens
then. From what I've read, if that doesn't work, you might try Lindstrom -
he seems to be able to get things through sometimes.
Good Luck.
— Carolyn M.
March 18, 2003
I agree with the others. Do the diet. The next 6 months are going to pass
no matter what you do. Be sure to have your doc put EVERYTHING in your
record so you can show Aetna.
— SarahC
March 18, 2003
I don't know if you will find this helpful or not, but I was approved by
Aetna (PPO) last week on the first try, less than a week after I submitted
my part of the documentation. My surgeon submitted the request and my PCP
submitted a letter of medical necessity (which I essentially wrote for her)
which supposedly wasn't necessary, and then my burden was collecting 5
years of medical records from three different places and organizing the
papers into a coherent package that proved the several things that Aetna
wanted. I circled the dates and weights on my two PCPs' progress notes; I
circled the words "obesity" wherever they occurred; I circled the
mentions of my "comorbidities" (GERD, IBS, edema -- fortunately,
nothing serious yet); I circled the mentions of diet advice and diet
medications and other "counseling" as well as the lack of effect
they had; etc. <P>
But as for the supervised diet, etc., I was fortunate in one respect --
about 18 months ago I joined a clinical trial for an obesity medication
(which, sadly, didn't work for me at all, even for the three months that I
KNEW I was on the real stuff and not the placebo -- though I might have
been on the real stuff for the first year too, but I don't know). I wasn't
sure how they were going to take the "progress notes" of the
clinical lab doctor and the clinical staff who checked me every month, but
I had monthly weights, notes that I had been counseled on dietary,
nutrition and "lifestyle changes" -- yeah right, you try to get
exercise when you need 3 hours every morning to go to the bathroom because
of IBS before you get out of the house; you work 10-12 hours/day (mind you,
at my dream job, but still!) and travel over 2-1/2 months out of the year
in 4-14 day chunks -- even the staff was sympathetic, but the progress
notes did say I didn't (or couldn't) comply -- and when you lug your 140
lbs overweight almost 50 year old body home at night, the last thing you
want to do is go exercise -- all I want to do is eat dinner, and then nosh
for the rest of the evening.<P>
Anyway, Aetna found that paperwork, both regarding my medical history and
"supervised diet" acceptable, as well as my arguments about how
tall I am (if you can imagine, my PCP 5 years ago said I was 5'4.5"
[which made me cross the threshold to MO exactly 5 years ago], my current
PCP rounded up to 5'5" [which meant I would have had to wait until
September to be MO for 5 years] and my surgeon's office has a Procrustean
tape measure that had me at 5'6" -- which would have caused me to wait
an entire 'nother year to be MO for 5 years!) and approved me right
away.<P>
And now you're thinking -- well goodie for her -- but don't worry, they had
a catch for me. Despite Dr. Rabkin's request for authorization for a
DGB/DS (= BPD/DS), my PCP's letter asking for it and MY letter asking for
it, my approval (funny, they actually have the nerve to write: "The
following has been REQUESTED:" -- WAS NOT!!) is for "GASTRIC
RESTRIC PROD,W GAST BYPAS-MORBID OBES; W SHRT LIMB ROUX-EN-Y" -- no
explanation why the procedure that was requested was in essence denied. SO
-- it's off to fight the APPEAL battle for me anyway.<P>
What really gets me about this most of all is that Aetna has no valid
reason to deny this procedure -- the cost for the RNY and DS is the same.
The surgeon, PCP and patient ask for one procedure and all three requests
are ignored. What I would REALLY like to do is to MAKE them acknowledge
that there is NO REASON to deny the DS, for ANYONE. But I will probably
have to do something I don't want to do, which is to argue MY particular
situation (both maternal grandparents died of stomach cancer; therefore,
leaving me with a blind stomach pouch inaccessible to endoscopy, which is
what you get with the RNY) and my guess is Aetna will probably (I hope)
approve me to shut me up -- otherwise, if I appeal using my own legal and
scientific skills (I'm both a PhD scientist and lawyer) and those of the
Lindstroms, they might have to give in to everyone, and for some unknown
and probably unspeakable reason, they don't want to do that. Perhaps
because "the powers that be" at Aetna find it morally troubling
that the DS provides (for some, not for all) a more normal manner of eating
after the weight is lost (or so I've heard) and doesn't punish the
"gluttonous" who eat sugar by dumping (well, those of us without
a serious sweet tooth don't NEED that -- I need my negative feedback
[diarrhea and stinky poop] for eating greasy things!) -- perhaps they think
the DS doesn't require enough long-term suffering and sacrifice? I don't
know, I truly don't. The reasons on the Aetna Coverage Bulletin for MO
Surgery is full of half-truths, ridiculous issues (they complain that the
DGB/DS hasn't had "randomized clinical trials" -- but the cold
scientific truth is (1) what patient in their right mind would agree to be
randomly assigned to one of two major surgeries, each of which has
different risks, different rationales, different recoveries, different
long-term outcomes, different lifestyles required, different foods to eat,
without knowing what it was going to be?; (2) because of the different
recoveries, different long-term outcomes, different lifestyles required,
different foods to eat, etc., THE PATIENT CANNOT BE BLINDED to what was
done!; and (3) for the selfsame reasons, there never have been RCTs done
for the RNY either, just longer (than the 18 years that DS has been done)
times that data has been available because the surgery has been done for a
longer time.<P>
Argh, I'm sorry for being so longwinded, and so pro-DS -- please don't take
this as a dismissal or a putdown of RNY -- I know it is the right surgery
for some people and that the DS is right for others -- what I am upset
about is that I (and my surgeon and my PCP) think the DS is right for ME
and I am INFURIATED that Aetna has the unmitigated gall and audacity and
lack of integrity to treat ANY MO patient the way they do. Can you tell I
got my letter today and tomorrow is "Write the Appeal
Day?"<P>
But I DID want you to know that Aetna's criteria CAN be met, and (honestly,
quite to my surprise) even on the first try. But then they knew they
weren't at risk yet, because they KNEW I would still have to appeal to get
the procedure I want. So, don't give up -- frankly, if you start the diet
counseling now AND GETTING IT ENTERED IN YOUR PCP'S PROGRESS NOTES FOR
LATER SUBMISSION TO AETNA, by the time you get all the other things done
(sleep studies, quitting smoking, psych eval., etc.), the six months will
probably be almost over anyway. Best of luck to you in beating Aetna
down!! Diana
— [Deactivated Member]
March 18, 2003
I am also waiting for my rejection. I have been to many weight loss
programs on my own because my PCP recommened it. He never documented it.
He also wouldn't give me diet prescription pills because of a thyroid
condition and high blood pressure. Now I have an appt. with a dietician
and I will make sure my PCP documents the info. But how does one document
exercise?
I am also concerned that by the end of the 6 months, they will change their
criteria again.
— Katerina M.
March 18, 2003
I just wanted to add that you can document exercise by joining a gym and
document when you attend. The Y has a neat computer program called FitLinxx
and you can record every workout you have done and get it printed.
— SarahC
March 19, 2003
I too have Aetna. I was denied my first try due to the 6 month supervised
diet. I had the 6 month supervised diet, but my dr. did not list in her
notes what diet I was on, so they wouldn't accept that 6 months. I had to
start all over again. After being denied, I was diagnosed with high blood
pressure and Diabetes. I went back to my surgeon and he resubmitted all my
paperwork. I only had 4 months for my supervised diet at that time. My PCP
also wrote a letter stating that she felt it would be benifit my health if
I had the surgery. Even without having the full 6 month diet history Aetna
approved the surgery after my 1st appeal. Whatever you do, do not give up.
It will all work out. If you have to wait 6 months for the diet history,
then wait the 6 months. It has taken me a full year to get to where I am
today. It has been a long and frustrating year, but it has paid off. I
should have my surgery the end of April, or the first part of May. Good
luck to you.
— Tonya W.
March 19, 2003
I had not planned on answering the question but I am on my father's
insurance plan and he has Aetna. I was worried about being denied because
I did not have the doctor supervised diet. My surgeon recommended that I
write a letter to Aetna to be submitted with her paperwork. In the paper I
included my diet history (I found my medical record from birth to 17. I
listed all the diets I had been on and my BMI at various times. I broke it
down to Elementary/Middle School, High School, and College/Grad School. I
also talked about my family history and mentioned the health problems and
Obesity levels of several family members. I have 3 family members who have
also had various forms of WLS and mentioned that. I also mentioned several
times that my request for WLS is not one of vanity rather it is of fear of
. . . (and listed the health problems that could happen). I also had my
PCP write a letter stating that he has seen me for this amount of time and
my BMI and that he feels that I am a good candidate for surgery. I hope
that this helps you. I was approved after my first letter and will be
having surgery next month. Good luck!!!!
— Melanie S.
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