Recent Posts

BethR311
on 9/29/10 2:23 pm - Fort Wayne, IN
Topic: RE: HOW DOES "SELF INSURED" affect approval
It doesn't, much.  "Self insured" means that all Aetna does is administer claims and benefits (including surgical approvals) paying out your employer's money, not Aetna's. 
        



    
Open yourself to possibility and possibility will present itself.
Jeanine J.
on 9/29/10 5:29 am
Topic: Harvard Pilgrim?
Harvard Pilgrim Coverage - Does anyone have HP? If you do what are your experiences and comorbid conditions? Did you need any if you have a very high BMI?
dawnspaints
on 9/28/10 1:13 am - Carlyle, IL
Topic: blue cross blue shield anthem and panni removal
Has anyone been able to get this done?
Kelli S.
on 9/27/10 7:02 am - Kalamazoo, MI
Topic: RE: Super Freaked out and nervous!
Oh yeah, even at my lowest with my PCP my BMI was still over 40. I will keep everyone posted on how it goes.

I am 27 years old, 5' and 3/4" tall. HW: 263 SW: 226 LW: 142 CW: 198

Nan2008
on 9/27/10 6:13 am - Midland, MI
Topic: RE: HOW DOES "SELF INSURED" affect approval
Yes, Aetna is still who approves or denies.  I am curious too, if your BMI is 62 and you have fulfilled the other requirements, I can't imagine what it must be other than the 2 year history thing.  Both my daughter and a friend of mine were denied for that exact reason 'lack of proof of obesity for the past 2 years' even though they had 3-4 years of medical history submitted !  Do you know for sure that your surgeon's office (or did your PCP submit for approval??) included your medical history proving you had a high enough BMI fo rthe past 2 years without dropping below the required BMI?

Nan

HW 300
/ SW 280 / CW 138 /
GW 140
Hit Goal 4/2/2010

        
Nan2008
on 9/27/10 5:51 am - Midland, MI
Topic: RE: Super Freaked out and nervous!
It sounds like you have everything under control!  I would definitely check with the MD from the 90 day program and ask if they are requesting your past 2 years medical records because you will need to submit them with your paperwork in order to get an approval by Aetna.  And make sure your BMI did not drop below 40 in that 2 year history !  They will deny for this also.  (or BMI of "35-39.9 with co-morbidies. 

But yes, definitely get your medical records to whomever is going to submit for approval.  Not sure if the MD from the 90 day program automatically does that or if it's something you have to initiate.  Sounds like they have a good program in place though for meeting the requirements!

Nan

HW 300
/ SW 280 / CW 138 /
GW 140
Hit Goal 4/2/2010

        
Kelli S.
on 9/27/10 5:35 am, edited 9/27/10 5:48 am - Kalamazoo, MI
Topic: RE: Super Freaked out and nervous!

Thanks for the information. It is 90 days, and it is done in the sugeons office through their "medical weightloss clinic" that is monitored by an MD. I have weekly classes and weigh ins that include every other week classes with the nutritionist and behaviorist (behavior modification).

Do you think it is wise to get records from my primary care doc that I have noting my weight from the past 2 years or do you think the MD from the 90 day program will get it for me?

Also do you think it makes a difference since my insurance is backed by the Teamsters Union? 

I appreciate your help!

I am 27 years old, 5' and 3/4" tall. HW: 263 SW: 226 LW: 142 CW: 198

mrsconrad
on 9/27/10 5:15 am - Steger, IL
Topic: RE: HOW DOES "SELF INSURED" affect approval
so its still aetna who approves or denies???  I am just trying to come up with some reason this is occurring... still waiting for the letter... : )
Nan2008
on 9/27/10 4:57 am - Midland, MI
Topic: RE: HOW DOES "SELF INSURED" affect approval
Doesn't affect it at all.  My company is self insured also.  It just means that the company pays the claims.

Nan

HW 300
/ SW 280 / CW 138 /
GW 140
Hit Goal 4/2/2010

        
Nan2008
on 9/27/10 4:55 am - Midland, MI
Topic: RE: Super Freaked out and nervous!

It is TOTALLY worth it.  I was denied for surgery because my surgeon's office submitted my paperwork to soon.  I too was doing their 3 month multidisciplinary program.  My surgeon's office submited the paperwork thinking I had completed it with my PCP.  I had not and was denied.  I finished the 3 month MD program, appealed, and won.  I had surgery in March 09 and have lost 160 lbs.

A friend of mine was denied by Aetna also.  Reason being 'lack of proof of obesity for 2 years'.  I helped her with her appeal and she was approved and had surgery in Jan 2010.

My daughter was also denied.  I appealed for her, and she won!  Had surgery this past May and is down 78.5 pounds.

So yes, it can be quite discouraging to hear all the stories of how Aetna is so hard to get approved, but basically, if you meet all of their requirements in their clinical bulletin 0157 (I'm assuming you have that already) you will get approved.  You just have to make sure all of your T's are crossed and your I's are dotted!  And if you are denied, get the reason why, and prove to them what they need to see.

One thing to keep in mind, it is not a 12 week program according to one of the Aetna appeals team member's I talked to.  It is a 90 day multidisciplinary program.  The wording when I was getting approved said 3 month multidisciplinary program.  He said this means 90 days!!  No less or you will get denied.  So make sure your first appoint and your last appointment with your PCP are at least 90 days apart!

I will PM you if you'd like a breakdown of everything I did to get approved.  Also, when talking to the Aetna representative, they stated the importance of the 'behavior modification' and that being documented with your PCP.  So make sure you are meeting all of the requirments as stated in the 0157 bulletin.

Good Luck to you!

Nan

Nan

HW 300
/ SW 280 / CW 138 /
GW 140
Hit Goal 4/2/2010

        
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