Your Aetna experience?

dogluvr · 01-07-2008, 04:14 PM

I have my 3rd apt out of 4 with the "3 month" physician on the 25th... and my 90 days is over end of next month. I did my sleep apnea overnigth testing over the weekend... and am getting my medical records together, although I do not have 5 years in a row, I have 12 years of being pretty grossly overweight. So we'll see- its going to come down to whoever reviews my file and if Im denied Ill appeal it. Hope everyone else keeps chuggin along as well!

JDUB0414 · 01-07-2008, 09:44 PM

we luckly found one. He went to the knee doctor one year and a clinic another year. so hopefully it will work. He has an appt on wednesday. which will give our pcp with a record of 2006/2007 and now 2008. do you think they will take the current 2008 one?

circa · 01-08-2008, 12:35 PM

Quote:

Originally Posted by JDUB0414

we luckly found one. He went to the knee doctor one year and a clinic another year. so hopefully it will work. He has an appt on wednesday. which will give our pcp with a record of 2006/2007 and now 2008. do you think they will take the current 2008 one?

absolutely! They took 2007 for me when it was 2007! :) They most definitely should take it! Good luck to you!

circa · 01-08-2008, 12:45 PM

Well I just found out that I was denied - Aetna says its not medically necessary. UHHH WHAT?! I met ALL of their requirements and I weigh 270 f*cking pounds. How is this NOT medically necessary?

coolcrystal · 01-08-2008, 12:59 PM

Quote:

Originally Posted by circa

Well I just found out that I was denied - Aetna says its not medically necessary. UHHH WHAT?! I met ALL of their requirements and I weigh 270 f*cking pounds. How is this NOT medically necessary?

Wow, this is scary!! I'll be submitting to Aetna tomorrow and I'm like 290 and fear the same thing. Is there anyway you can appeal it or something?? I don't have diabetes or anything like that and though I have sleep apnea, my test was inconclusive because I never went to sleep.... so what if they say it's not a medical neccessity for me either?? BUT, their requirements say 40 BMI OR 35 and above with co-morbitities.. so, I still don't get why you were denied!! Unless you are like 6'3", but I doubt you are that tall. That's BS.

circa · 01-08-2008, 01:04 PM

Quote:

Originally Posted by coolcrystal

Wow, this is scary!! I'll be submitting to Aetna tomorrow and I'm like 290 and fear the same thing. Is there anyway you can appeal it or something?? I don't have diabetes or anything like that and though I have sleep apnea, my test was inconclusive because I never went to sleep.... so what if they say it's not a medical neccessity for me either?? BUT, their requirements say 40 BMI OR 35 and above with co-morbitities.. so, I still don't get why you were denied!! Unless you are like 6'3", but I doubt you are that tall. That's BS.

No clue why I was denied. No, i'm not 6'3". Yeah, you can appeal this stuff, but I'm trying to figure out what deems me not medically necessary....I meet and or exceed every requirement. I have the full history. I have over 6 months attempt at weight loss with my PCP, including weightloss drugs! I have a qualifying co-morbity - although its not sleep apnea - it seems those with sleep apnea get put in the express-line for approval since it can be so harmful to your health

circa · 01-08-2008, 01:15 PM

Okay I found out the problem - the center didn't send over all the docs - so I let them know they need to send them and right away so it can get overturned. Freaking idiots - I have had nothing but problems with the people in the office there. If the surgeon wasn't the best around, I'd change.

coolcrystal · 01-08-2008, 01:18 PM

I'm sort of dealing with something like this too.. I'm scared they won't submit everything they need to and will cause some issue with me not getting approved. Especially since they acted very non-challant about one important thing that needed to be sent to aetna... Well, now that they get all the information they need, lets hope you get approved!

NeNe967 · 01-08-2008, 01:19 PM

I have Aetna. They are very strict about their requirements. I have to do the 3-month supervised pre-op diet. Hopefully I will be approved sometime in March. Good Luck!

circa · 01-08-2008, 01:32 PM

Okay - for those of you submitting, here's what I suggest. If you call the day after they submit, and get a status, it'll probably still be "pending" - that's fine - ask why - sometimes they'll tell you they're waiting on something. You can call your surgeon's office and have them send it, resend it or you can send it yourself if you have it. Call EVERY DAY for a status. If something is denied, ask what was missing, etc. and follow up on it right away - if you get a 24 hour turnaround, it will just get reversed and you don't have to wait the 30 days for all the appeal crap is what they told me. Here's the info you need

1. Phone number to precert department: 800-333-4432
2. Your Aetna member number and name (that one should be easy, lol)
3. Ask for the status of your precert for your surgery.
4. If not approved ask why and what's needed for approval. Also get your reference number.
5. Get your surgeon's office or you can fax the missing info to 859-455-8650 attn: Precert department with your Aetna member number and your name and your reference number on the cover sheet. Call the next day to check that they received it and for status

Always keep a log of when you called, who you spoke to and what they said!

NeNe967 · 01-08-2008, 01:38 PM

Thanks Circa for the info. I guess I will be appealing when I finish the 3-month pre-op diet.

circa · 01-08-2008, 03:45 PM

So apparently, my doctor didn't make enough notes regarding my weightloss visits for Aetna's liking. Because he didn't note in there every time I visited him regarding my weight that I was to continue exercise and strict diet of X calories, they dont' consider it a weightloss visit, even though I was given a new prescription for phentermine, weight was discussed, etc. So also because I had problems getting phonecalls back from the diagnostic dept, I don't have the 4 months pre-op that I could have easily had since my first appointment was in September either. So I have nothing. I have to start over.

JDUB0414 · 01-09-2008, 09:13 AM

Circa, that is ridiculous!!! Instead of me sending the entire file. My doctor sent a letter on her letterhead, with the year and weight I was at that year. It look similar to this.

2007-340lbs
2006-320lbs
2005-300lbs

So on and so forth. the reason my husband want approved was because he only had two years. we found the other three years and will be sending them asap. Because he didnt have them, they also deemed him not medically necessary...he weights about 310lbs!!!

circa · 01-09-2008, 08:17 PM

Well, I found out later that the surgery center DIDN'T SEND my 6 month weight loss visits - they didn't even send them! So I got denied and now have to wait for an appeal because they screwed up. I'm so very not happy.

kRiStI wItH a I · 01-10-2008, 02:45 PM

:omg:

I am soooo scared after reading all of your posts!!! I have Aetna POS II, and am doing the 3 month Nurse Pract/Dietician weight loss visits. I will be done with those mid-March. I have a flow chart from the Dr. office in another state for 2003 and 2004 and from a gyn and pulmonologist for 2005 and from my ob dr. for 2006 and from my PCP for 2007 and 2008. Will that make a diff that they are all from different places? I also have sleep apnea and have a BMI of 48.

I wish you all luck!!!! :clap2: Hopefully I will get approved. :nervous

Kristi