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Topic: RE: AETNA approved then denied. any help appreciated
thanks Nan.. I appreciate your reply & help :)
Topic: RE: AETNA approved then denied. any help appreciated
Hi
I sent you a PM. If I'm reading it right, you were denied because you did not complete their 3 month Multidisciplinary or the 6 month physician supervised diet. I'm thinking that besides the Revision requirements, you also have to meet the requirements for bariatric surgery which would include a physician supervised diet, along with BMI >40 or >35 with 2 co-morbidies, and proof of 2 year history of obesity.
Check out the PM's I sent you!
Nan
I sent you a PM. If I'm reading it right, you were denied because you did not complete their 3 month Multidisciplinary or the 6 month physician supervised diet. I'm thinking that besides the Revision requirements, you also have to meet the requirements for bariatric surgery which would include a physician supervised diet, along with BMI >40 or >35 with 2 co-morbidies, and proof of 2 year history of obesity.
Check out the PM's I sent you!
Nan
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
Topic: Are nut & psych evals covered by Cigna?
I know I will find out "soon enough" and could probably (gasp!) call them to find this out but does anyone know offhand if the nut and psych evals required by insurance covered by insurance? I know the 6 month of diet documentation wasn't but I keep hearing that those are both EXPENSIVE ($500+) for one time visits(?)
Topic: RE: How did you do your 6 mo. of medically supervised WL if your insurance required it?
My insurance required it as well and it wasn't covered (I find that ironic but anyway...)
I, too, had to pay out of pocket for visits with the exception of blood work that was also required. My insurance paid for that.
I, too, had to pay out of pocket for visits with the exception of blood work that was also required. My insurance paid for that.
Topic: RE: Insurance Reform Resources FYI
Is it easier to get insurance coverage if one's BMI is over 48 ?
Topic: RE: Denied (Again)
i would definitely get my surgeon to perform upper GI as it seems from their letter they need proof other than inadequate weight loss of problems. i actually told my surgeon we needed to do that before we submitted for revsion (i had vbg) and he declined; guess what.. i got declined (after they approved me verbally). good luck!
Topic: RE: Surgery this month or wait till Jan?
if you get an approval.. how long is it good for? also, you should get plenty of notice on what your insurance will or will not be before january (we got our paperwork in today for next year to review policies/options).
i personally would not risk loosing my wls & waiting until january. good luck!
i personally would not risk loosing my wls & waiting until january. good luck!
Topic: AETNA approved then denied. any help appreciated
Aetna approved me verbally, then sent denial letter for revision. Their reasons are because (1)6 mos diet and/or (2) 3 mos multi behavioral surgery prep. My surgeon is trying to get peer to peer.. they have granted it but playing phone tag. In the meantime, I went to website and this is what I found re: revision. My question is.. is does NOT state for revision the above is required. Anyone have any tips on appealing this or what I should do. I had original VBG in 1998 - lost about 80 lbs gained it back plus 50. Current BMI is 47; high blood pressure; high cholesterol, (meds for all as of 3 weeks ago); and my PCP decided to not treat for diabetes because I was having WLS this month (this was before Aetna took back their approval) Thanks for your help.
Repeat Bariatric Surgery:
Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction, stricture, erosion, or band slippage.
Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:
- Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
- Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
-
Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments.
Topic: Surgery this month or wait till Jan?
Ok so it's taken about a year to get everything I need together - the only thing I need is 1 more PCP office visit to complete my 6 months of diet/exercise documentation and then a nut eval and psych eval (which I HOPE I can get done this month!)
ANYWAY...I know the "no brainer" answer BUT I am going to throw my question out there anyway...
Soooooo I (like many others nowadays) am on a strict budget. If I can get approved for my surgery by the end of this month, I will owe about $4000 upon check in at the hospital. Anyone know if this has to be paid in full? My surgeon's office told most people do a partial payment and then smaller payments to pay it off. If this is the case I want this surgery ASAP but how much would/should I have in hand to apply toward my deductible on the day of surgery?
MY "worse case senerio" my insurance is either going away fully OR it's going to be much better...by that I mean that beginning in Jan it would only be $1500 deductible and I would be able to get FSA (Flexible spending account) to cover it.
I won't know till end of the month which "worse case" - as that is when enrollment and contracts will be finalized.
I know waiting till Jan would be the smarter move financially but scared if I wait it won't be the option I get delt. ANY ADVISE?
ANYWAY...I know the "no brainer" answer BUT I am going to throw my question out there anyway...
Soooooo I (like many others nowadays) am on a strict budget. If I can get approved for my surgery by the end of this month, I will owe about $4000 upon check in at the hospital. Anyone know if this has to be paid in full? My surgeon's office told most people do a partial payment and then smaller payments to pay it off. If this is the case I want this surgery ASAP but how much would/should I have in hand to apply toward my deductible on the day of surgery?
MY "worse case senerio" my insurance is either going away fully OR it's going to be much better...by that I mean that beginning in Jan it would only be $1500 deductible and I would be able to get FSA (Flexible spending account) to cover it.
I won't know till end of the month which "worse case" - as that is when enrollment and contracts will be finalized.
I know waiting till Jan would be the smarter move financially but scared if I wait it won't be the option I get delt. ANY ADVISE?
Topic: RE: How did you do your 6 mo. of medically supervised WL if your insurance required it?
Nan, did you have to do 6 mos medically supervised plus 3 mos multidisciplinary program?
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