circa

It really depends on how its presented to Aetna, would be my guess. If your doctor has documented 6 months of weightloss visits (3 of which are consecutive) in the last 2 years. If you have that, you'll meet the requirements

Have you gone through the 6 month weightloss with a physician? Do you have the 5 years of documentation of your BMI being 35+? If you do, they can't deny you. It follows the clincial policy bullitin Obesity Surgery Selection criteria: Presence of severe obesity that has persisted for at least 5 years, defined as any of the following: Body mass index (BMI)* exceeding 40; or BMI* greater than 35 in conjunction with any of the following severe co-morbidities: Coronary heart disease; or Type 2 diabetes mellitus; or Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea); or Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management); and [*]Member has completed growth (18 years of age or documentation of completion of bone growth); and [*]Member has attempted weight loss in the past without successful long-term weight reduction; and [*]Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary surgical preparatory regimen): Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet all of the following criteria: or [*]Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three months duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions: Consultation with a dietician or nutritionist; and Reduced-calorie diet program supervised by dietician or nutritionist; and Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and Behavior modification program supervised by qualified professional; and Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.) Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least three consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.); and Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records;

Has anyone else had a problem with the Surgery Center submitting your information to the insurance company? Mine neglected to send everything that was needed, which caused me to get denied which has caused me to end up in an appeal situation. This happened even after I walked them through every single document that needed to be submitted, then the person that screwed it up tried to blame it on ME and then tried to blame it on my advocate who gave her the information 7 times at least. I know this because I was BCC'd on the email that she sent to the person 7 of the times with the documents attached. I just wonder if anyone else has run into this.

Aetna doesn't pay for fills because they've negotiated them in the full price they pay for the surgery. I'm glad to hear your approval came through! Hopefully mine will go the same way! Mine is similar to yours - something was forgotten when the submission went - Hmm - wonder if we have the same person? lol

In dealing with Aetna and knowing what they're expecting according to their bulletin, you've gone above and beyond. I think you'll be doing just fine. You might need a few more months of diet and exercise, as Aetna requires 6 months in the past 2 years, but only 3 have to be consecutive (this is for a typical standard approval) Now, you may have extenuating circumstances that may change that - but you look like you're pretty well set.

Yah - I loooove the "have you tried weight watchers" or "what about jenny craig?" No - I didn't try those...I thought I would go the extreme route of having surgery instead of trying things that are readily available to me...FREAKING DUH of course i tried them!

<p><p><p>&lt;p&gt;As for 'starvation mode' - does it exist? YES - for those like Nicole Richie and Paris Hilton. Your body may conserve energy, but you will not go into starvation mode if your body is not starving. Not a darn one of us here has an issue with our bodies starving &lt;img src=&quot;http://www.LapBandTalk.com/images/smilies/happy.gif&quot; border=&quot;0&quot; alt=&quot;&quot; title=&quot;&quot; smilieid=&quot;60&quot; class=&quot;inlineimg&quot; /&gt; No one with extra weight has an issue with their bodies starving....Overweight people will never starve. They may feel hungry, but no, your body has plenty of fuel to burn. However, a bag of antlers like Nicole Richie was before she was pregnant (she actually looks healthy right now) will slow down. It will conserve - its self survival. But no, your body doesn't think &amp;quot;Hmm...those size 18 pants are getting a little baggy and I haven't had a snickers in 2 weeks. That's it, I'm on strike - everything I get put in me gets thrown directly on the hips! Broccoli, tofu, all of it!&amp;quot; &lt;img src=&quot;http://www.LapBandTalk.com/images/smilies/happy.gif&quot; border=&quot;0&quot; alt=&quot;&quot; title=&quot;&quot; smilieid=&quot;60&quot; class=&quot;inlineimg&quot; /&gt;&lt;/p&gt;</p> <p>Also, a typical day of food for me when I was in training was about 850-900 calories accompanied by about 600 calorie burn in exercise on top of my BMR - I did that for a long time and never felt better in my life.</p></p></p>

Its great if they can lose weight and keep it off without a surgical assistance. It seems to me that there's a lot of envy in this thread about it though...Some people CAN and DO lose weight and keep it off without a band or a bypass. Examining their lives in 3 years may very well show the same results as what they have now. There are people who DO have surgical assistance that are bigger 3 years after getting it than when they first got it as well. I think that if it works for them, that's great. Hell, it worked for me until I was basically bedridden and force-fed steroids that made me gain 100 lbs in a year

most people aren't going to notice how much you did or didn't eat. The more you talk, the less you eat. Its rude to ask someone why they're not stuffing themselves :girl_hug: I would just say that you weren't very hungry and you were enjoying the conversation so much that your food got cold - you'd rather take it home and savor it warm

Okay, I just got off the phone with Aetna. Lemme tell you something about Aetna. I have had NO problems with them. They have approved things that most insurance companies still consider experimental. They had no problem with me switching to a birth control that they don't cover (and is WAY more expensive) because its the only one on the market that doesn't contain copper as a binder (I can't have copper). They've paid for weekly infusions and "experimental treatments" because the treatments I need for the medical condition I have, I'm allergic to. They didn't blink twice. All I had to do was send a letter from my doctor with my official diagnosis along with my medical indications - allergies, etc. and they rubberstamped it. I have had NO issues with them. I just got off the phone checking the status of my appeal. I explained to them that I wouldn't be in this situation if the center had sent the records in the first place. The Aetna lady put me on hold and physically walked the documents that were missing over to the reviewer and told him to get on it ASAP. She was very reassuring and even apologized for the mixup, even though it wasn't Aetna's mixup. I haven't been approved yet, but I know if its up to Aetna, I will be. Unfortunately, its not just me an Aetna, I have to deal with people who are less than adequate at their jobs as well...sortof Monkeys in the middle, I guess. Just relax and know that if you follow up and you meet the criteria, they will approve you. Sometimes it might take an appeal or two, due to the fact that something isn't quite clear and needs to be explained, but overall, I can't say enough GOOD things about Aetna. I had BCBS of Alabama once. Yeah - they can go suck an egg. They wouldn't pay for birth control, but they'd pay if I wanted to pop out 15 kids. Geesh

Don't be scared! If you meet the criteria, they won't deny you. You just have to make sure that you do meet it. It absolutely doesn't matter where the records for your history come from - Mine are from about 10 different doctorts in 4 states and that's not a problem. You just need to make sure that your however many months of attempted weightloss are from the same place Besides, mine's not an Aetna issue, its an incompetence issue with an office person at my center.

i've noticed that the people that say things like this have vices of their own - smoking, drinking, breathing...etc. Ya know, you don't have to breathe all the time to stay alive - so tell them to stop breathing when its not absolutely necessary

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.

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.

my surgery is coinciding with me ending a year long steroid regimen that has caused the majority of my weight gain so I'm just telling everyone I got off the steroids. :eek:

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!

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.

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

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?

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

I called Aetna today - they have my stuff - they said it was in pending status but I have a surgery date listed of 1/21/2008 (that's gonna hafta change, lol) but he's checking as to why it says its pending when everything appears to be in order...

do you have anything? a visit to the ER or a walk-in clinic? That may have his weight on it. Also, if you have previous records that shows his weight issue that's older, that may help. Maybe a letter from his physician would help as well.

Okay, I was finally submitted to Aetna today. I'm calling them on Monday for a status haha. I wanna get this done! :confused: Wish me luck with the approval drones!

I would speak to your father's friend - the doctor that treated you. He would be able to summarize your medical history for the insurance company. This may really be helpful for you. I found that since I had a lot of pertinent information missing from my medical records, having the doctor write a history of what my weight was like during the times he treated me, it really did help. Anything is worth a shot.

Thus far, my experiences with Aetna for everything have been rather pleasant. I have another condition that, I'm allergic to the treatment for - they approved an alternative treatment just based on the fact that I have a known allergy. Now, I'm attempting to get an alternative to the alternative - since the first alternative isn't working as well as expected. They denied my first 2 requests but my third has been tentatively approved pending an independant specialist review. I have not submitted my lapband paperwork yet, but I"m working on that.