Question:
Can anyone tell me if my diet history is good enough for approval with Aetna?
Still waiting for RNY approval from Aetna, took them only 1 day to deny me for DS though!!! Was told yesterday that my surgeons office had 3 denials this week alone, I am getting scared I go in on June 24th.I have a great nutr. leter and Psych. letter, my PCP wrote a 2 page great letter too,listing reasons why I should have this surgery, as far as the diet history she went back to Jan 2002 (1 yr. and 4 months documentation) examples: Jan. began weight watchers 250 lbs. March down to 240 lbs. May weight is 255 lbs. began swimming program July 245 lbs. began Richard Simmond weight loss progaram and began walking..etc. The Dr. did this up until recent is that good enough? I hope their not looking for month to month, I never checked in with my Dr. on a monthly basis, mostly bi-monthly. Does this sound ok to anybody? I am geting very anxious!!!!! — jane O. (posted on June 5, 2003)
June 4, 2003
If you have Aetna PPO like I do then unfortunately
probably not. Since January they are requiring medical
record of a medically supervised diet ie: optifast, HMR etc.
This evidence must support a medically supervised diet
for a duration not less than 6 months in length and must
have occurred no more than 2 years prior to your surgery.
good luck and hope this helps.
— Mark
June 5, 2003
The big question is did your Dr. document this in your medical records?
According to their "rules", a Dr.'s letter is not sufficient. It
must be documented in medical records. If your Dr. put your weight
watchers information in your record (as mine did) and you sent your WW
weigh-in booklet showing at least 26 weeks of membership (not necessarily
26 weeks of attendance)and if during this time you seen a nutritionist
(which also has to be documented in medical records)and you can show
something where you were exercising (club membership, etc), it might be
good enough.
If it is not all documented in PCP records, it won't enough.
Fortunately, my PCP noted in my records that I was joining WW, I seen a
nutritionist on my own and took a copy of that report to him so that was
noted in my records and I joined the YMCA and met once with a trainer to
set up an exercise regimen and I sent copies of everything (WW weigh-in's,
nutritionist paperwork, exercise, in addition to PCP medical records)and
was approved after appeal. They didn't get all of this the first time and
they denied me.
Good Luck
— Carolyn M.
June 5, 2003
Call your company advocate and get on them for not supporting their
wellness programs. Also, build a spread sheet of all the diets you can
remember and approximate dates. Some of these will be in the doctors
records and you have a right to look through your records at the doctors
office. Help the process along with some of the research needed to prove
your case, that is what it took for me to get it approved and I was still
very worried. Stay on them and do not give up, ever!
— Bill B.
June 5, 2003
I hate to be the bearer of bad news but Aetna and CIGNA are requiring the 6
month (within a year)of medically supervised diet (with at least a monthly
weigh-in). My Counselor fought Aetna for 18 months! It was not good news
to me, either!
Good luck - don't give up - that is exactly what they want us to do so they
won't have to pay.
— Sunie I.
June 5, 2003
Jane...just provide them with all of the documentation that you can...the
diet history...copies of your charts with your PCP for the last couple of
years...etc. My wife did not have a documented physician-supervised diet
and exercise program. What she had was documentation of her weight over
the last year after she joined the fitness center at the hospital where she
works. Also, the charts detailed increasing problems managing her
diabetes (started out the year just on Glucophage, ended up with
Glucophage, Actos & insulin). She was approved by Aetna in February
on the first try and had her surgery 5/6/03. She's lost 27 pounds so
far...JR (open RNY 07/17/02 -177 pounds)
— John Rushton
June 5, 2003
Aetna wants a six month Dr. supervised diet within the last two years.
Richard Simmons, weight watchers, etc. don't count. I know they are being
really strict about this. They also want five years worth of weight
history. I was denied by Aetna in October for not being morbidly obese for
five years. I hired Walter Lindstrom to appeal it for me, and was denied
two more times. It went to external review where it was overturned. It
took seven months of fighting them.
— Robin T.
June 5, 2003
Hi, I was denied in April by Aetna for not having documented weigh ins and
documented exercise routing in my PCP's notes. He wrote a letter, however,
it is not sufficient. Even though you could see that my weight was
dropping, it has to be specifically written in his notes that you are there
that particular day to come for your weigh in and that you are still on
your exercise regimen. You should have heard what my PCP said when I told
him I was denied! Was he mad! My advice is to start the 6 month diet and
exercise regimen immediately. There is absolutely no way of getting around
it, unless you hire an attorney to fight it for you...and even then, you
may not get the result that you're looking for.
— Susan F.
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