[FatButNotHappy]

Hi, I have a question. I have Aetna and it does cover the surgery. I have completed my six month diet, done the blood work, sleep study, psych eval and nutritionist. I picked up my chart on tuesday and have had my chart at my house to send in, but I am putting it off because I am so worried about being denied.

My only problem is that for the last two years (all that is required) from 2007 until now, my bmi has been 38-41. In 2007 my weight was listed as "patient refused", then 219 and then blank (three different visits throughout the year.) It went up in 2008 and up more in 2009.....I do not think that in the last FIVE years it has even been below 35--but i only need a 2 year history.

I am wondering how illegal it would be to write my own weight in where they left it blank in 2007? It is BLANK...that seems like it should be fair game, right? I am half kidding because with my luck, I would end up in jail-but trust me, it is only the fear of getting caught that is stopping me--not my conscience.

My BMI was 41 in january and i think i lost 11 pounds since then. Will they deny based on the fact that my BMI was not more than 40 for the ENTIRE two years? i mean, hell--it isnt like i dont TRY to lose weight, but i always gain it back...and there is a good chance that on the other 362 days of 2007 my BMI WAS actually over 40--i just wasnt at the doctor on those days.

I did collect a stack of photos taken during the last five years which will easily prove this is not a recent, acute weight gain...and that i have been fat for several years--if not MOST years during my life. Will those help?

Please give me hope!!!

[MsVickie]

Actually they have to take it all in two account before making a decision. I Wouldnt think that will stop it. If your surgeon even thought it might be denied he would tell you. They are all getting aquantied with insurance companys now and know the drill.

Your only costing your self a chance at a better more healther life sooner than if you put it off a while. I would submit it and go for it. There is always an appeal process to use if it is.

[4Kate]

I say go for it! What do you have to loose?

[DocSanae]

Welcome to the board, thank you for joining us.
Good luck with your process.
((((((HUGS)))))) May your journey go well.

[MsVickie]

Um honey I didnt see where you asked about placing weight in the blank spots until I just reread it. . I have no idea why they would do that just leave it blank. Im not gonna suggest you write in a weight. If your caught its called fraud. The insurance company will be the one comming after you. Send it like it is and im sure you will have the sucess you want. Just dont mess with the records. The pictures are a great idea with even a note.

[dixieladybug]

What I understand going through it myself is that as long as you have just one weight during the year that shows your weight it will work. Just send in the ones that show the highest BMI and weight. I had to go back and find a different doctor for the one weight i needed.. I had to show five years... I almost forgot that I went to a different doctor that year. It must have been ok I got approved. Good luck...

[Kelliebelly]

I work for Aetna. I'm going to provide you with a Website that will give all the criteria you will need to meet in order to have your WLS approved. If you do not have any risk factors with A BMI of less than 35, then your BMI will need to be 40 or higher. However, if you do have a BMI of less than 40 and you have a risk factor such as Diabetes, Sleep Apnea, Hypertension, that would meet the BMI criteria piece of the requirement for approval. Here is the Website. From the drop down box, select "Medical". Then in the field "Search CPBs" type "Bariatric Surgery" and click on "go". When you get to the next screen, click on "Obesity Surgery" and this will tell you all the criteria that is needed for approval. I actually printed this off and gave it to my Nurse that does the insurance information at the Bariatric Center. This will very helpful to you. I don't really recommend "fudging" your information, I don't think you'll need to do that. Most likely you will be approved. Aetna's Turn around time for approval is fairly quick and effecient. Good luck to you!!! Clinical Policy Bulletins (CPBs)

[FatButNotHappy]

Thanks for the replies.

I dropped off the stuff I had from my PCP and gave it to the insurance lady at the surgeon's office. She was somewhat concerned about my 2007 weights (one marked "refused" one for 219 and one left blank.) She is faxing a letter to my PCP to see if she can get a weight from 2006---in hopes it will be higher and honestly i do not know if it will be or not. IF i let them weigh me, i tried not to see what the scale said (denial is a powerful thing.)

I did have them weigh me and check my height again. I am only 5'4" instead of the 5'4 3/4" that my PCP had listed...so, that is good.

I showed her all of my pictures, but sadly none of them had a date on them...although a stack of them was from 2006-2008 and because I was in school at the time. Had pictures from my first day until my graduation ceremony in 6/08---I would have thought those would work but not without a date. Grrrr. She did suggest having me doc write letter stating i was her patient during that time and she would estimate my weight to be a certain amout and have it notarized. I can do that, if she will. She has been my doc for ten years.

Also, my pyscholigist that did the eval suggested further therapy, which i did...but they didnt send a follow-up letter-so, they have to wait for that too. grrrr.

thanks again.

OH and i wouldnt really fudge my numbers on my chart---but, damn...i have been tempted...i dont think i would do well in jail....it keeps me honest.