adagray

I talked to my PCP about WLS before I chose a bariatric surgeon so I let her know at that time that I would need a letter of medical necessity. Personally, I think its a good idea to meet w/your PCP earlier rather than later in the process. You will need that letter and if your PCP is not supportive, it would be best to find out right away so you can change PCPs, if needed, to get the support you need. If you already have things rolling w/your bariatric surgeon's office, though, I wouldn't delay starting the 6 month diet. Just meet w/your PCP and get that letter as soon as its convenient for you. As for whether you can be approved before or after the 6 month diet, my paperwork from Aetna says that you can submit before the 6 month diet is completed and they can approve you 'contingent on completion of the 6 month diet'. Originally, this is what I had planned to do. The insurance coordinators at my surgeon's office highly recommended against that. They said it puts up red flags if you submit without everything completed and that it might cause me to use up an appeal. I'm putting my trust in them since they are the insurance experts. As of tomorrow, I will have completed the 6 month diet and everything else and my stuff will be submitted to insurance. Ack! I'm so nervous!!! But, I just keep reminding myself if I get denied, it is not the end. Lots and lots of people on here get denied, but then approved later on appeal. So, we just gotta stay strong and hang in there. Best of luck to you!

I am so sorry they are leaving you hanging. But, if it makes you feel any better, it seems that every post I've ever read about a peer-to-peer conference ended up in an approval. Maybe there is just some minor clarification that needs to be made so they didn't want to formally deny and then have you go through appeal.

Just want to ditto what the previous poster said. Wait until you have the job offer, then ask to review the plan documents before you accept.

Definitely submit the heaviest weight from every year. So, if you were heavier later in the year, I'd get that documentation from your doctor and use that as your weight for that year. I actually just got my complete files from all my previous docs so I could pull out the heaviest weights myself. And, my bariatric surgeon's office also said they wanted just the heaviest weight from each year to send for the insurance approval.

Not the same situation, but my PCP offered to write a letter of medical necessity if I wanted a breast reduction. So, I think I would start w/my PCP and go from there.

Mine did not charge me, but I can see why some would cause it probably takes them as long as a regular appointment to write it.

If you have weights that are higher previous to 2 years, I'd submit those w/an explanation that the lower weight within the 2 years was temporary from dieting, but you could not keep it off. At least this is what my surgeon's office is going to do for me when they submit my paperwork. I can show weights high enough for the past 5 years, but in 2007 I had some success on WW and have a lower BMI. I know they will reject my first application. That's pretty much guaranteed. But, I think we may be able to get it on appeal.

Congrats to Laurie!!! Jodi, I understand your frustration w/the 3-month requirements. I read them to mean that you go to a nutritionist, exercise therapist, and behavioral therapist every month, but I don't know if I'm interpreting it right either. In the end, I decided to just do the full 6 months. In my case, I felt like I could use the extra time to get my head wrapped around this big change anyway. And, instead of going to my PCP, I'm seeing a doctor at my surgeon's office for the 6 months (and she is also a nutritionist). She's also been really good at helping me w/the psychological aspects of this all. So, I feel like the 6 months is worth it to me. So much of this is getting your head in the right place so I don't mind waiting a little longer. And, 3 appointments every month would be hard for me since I have two little kids.

I would recommend having a sleep study done to see if you have sleep apnea. Do a search online to see the symptoms of sleep apnea. Even if you just have one or two symptoms, ask your doctor to send you for a sleep study. If you are diagnosed w/sleep apnea, then you will have the comorbidity that you need for insurance. I am in a similar situation in that my BMI is 38 (not quite 40). I have high BP too and am on meds for it so I already had the comorbidity that I needed. But, I went for a sleep study anyway (because I have some symptoms) and turns out I have sleep apnea too. I hear it is really pretty common.

I know how you feel about the diet rqmt. I had been on Weight Watchers for 2.5 years already, but that didn't count since it wasn't doctor supervised. I thought the 6 month diet would be a waste of my time, but it actually has turned out to be quite worthwhile. I decided to do the 6 month weightloss through my bariatric surgeons office. The doctor/nutritionist knew that I could not lose much weight or my BMI would go to low so we worked on other habits rather than a strict diet. First, was to just do 10 min of exercise every day for a month, the next month my goal was to make sure I was getting at least 15-20 grams of lean protein at every meal, this month I am working on decluttering/cleaning out my pantry and closet/wardrobe and reading 'does this clutter make my butt look fat' and carnie wilson's book 'still hungry'. I haven't lost any weight on the diet, but I feel like these things are helping me prepare for the changes to come w/surgery. I'm actually glad I'm doing the 6 month diet now and am thinking I really need therapy after the surgery to make the most of this. The psychologist didn't say I need it, but I can see now how much of this is psychological.

Two things I recommend... 1) Meet w/your PCP and explain that you want WLS and explain what is needed for comorbidities. Ask who she/he recommends for bariatric surgery. And, ask for a letter of medical necessity. If your PCP is supportive, then they can be a great help to make your case for you and document things in your favor to get the surgery. If your PCP is not supportive, its better to find out right away so you can move on to one that is. 2) Get a sleep study done. I was sure I didn't have sleep apnea, but the more I learned about it, the more I realized I might have it. So, I went for the sleep study and sure enough, I have it. So, now I have two comorbidities (w/my high bp). Lucky me! LOL Aetna doesn't count high cholesterol as a comorbidity. Its something your doctor should still mention in the letter of medical necessity (as extra reason why you need the surgery), but that in itself is not enough to get approved. I wish you all the best w/this. Its quite a process. I'm not done w/insurance yet myself.

This is a great thread. So great I have to post again. LOL One thing that I have found is that the more I go to my bariatric surgeon's office, the less self-conscious I feel. I am going there for my 6 month diet so that is why I'm there so often. Anyway, its impossible to know what people are thinking and not fair to assume they are thinking anything negative. Yes, I feel like I've been looked up-and-down many times, but I'm sure I'm looking others up-and-down as well... not in a bad way, but I can't help but be curious if they are just starting out, which surgery they got or are getting, and how its going for them. So, I'm giving those looker-upper-downers the benefit of the doubt now, smiling, and saying Hi. Everyone has been friendly.

I'm 5'5" and 228. I would love to weigh 150ish (which is the top end of a healthy BMI for me). I am 39 and have spent my entire adult life either gaining weight or dieting (and being hungry). I've lost 50+ twice and gained it back. I do feel like a bit of a freak at the bariatric surgeon's office because I'm on the small side for this surgery. I felt a bit self-conscience at the seminar. But, anyone who would take the time to get to know my story would understand why I need this surgery. So, I try not to worry about what people think. In fact, I'm proud to be tackling my health issues and fears now rather than waiting for things to get worse.

Seems like Aetna makes a lot of 'mistakes' as far as denying a lot of claims the first time around that really do qualify. I hear it on here all the time. I also have Aetna, but am not through insurance yet for lapband. But, I've had to deal w/them on some other things (like the billing for my second c-section) and let's just say that they don't have their act together in a lot of ways. They also outsource a lot overseas (not saying that is bad, but quality can suffer, especially in the first review of things). I found that once I escalated my billing issues, they were resolved quite quickly. Its just the first go around they got at least half of my billings wrong. And, it was a nightmare because I was going to the hospital 2x per week up until the delivery date for stress tests so there were A LOT of bills for them to mess up! Anyway, hang in there. It does take some patience, but I'm sure you'll get it worked out w/Aetna.

To put things in perspective, the risks from this surgery are far far less than the risks of being severely or morbidly obese. Personally, I don't love the idea of this surgery myself. I'm not particularly scared of surgery (have had my appendix out and two c-sections), but I wish I didn't need it. But, I do so I will. Have faith. You will come out of this great!

I think as a fat person I've learned to let these remarks trickle off of me like Water on a duck. I don't let them get under my feathers. Most people are well-intentioned, but either misinformed or lack the skills to deliver the message in a way that is not offensive. So, I always try to look at intention. Now, as a funny side-note, I remember being REALLY offended at my former PCP because when I went in to see him after losing 40 pounds on WW (and told him I had 30 more to get to my goal weight), he told he didn't know ANYONE who ever took that much off or kept it off without bariatric surgery. I felt like he was telling me my efforts were futile and it made me mad. I ranted about him to everyone I knew, but it turned out he was right. So, I just have to laugh about that a bit now. Ironically, I may have a fight w/insurance now because my BMI went below 35 during this huge effort on WW and now I've gained it all back plus 20. Ugh! Hindsite is 20/20, though. I was just soooo not ready to consider bariatric surgery at that point so he was in a lose/lose situation no matter what he said. I think this is why so many doctors just keep their mouth shut when it comes to weight even though I'm not sure if that's for the best either...

Did they tell you why you were denied? It might be something as simple as missing paperwork. That seems to be very commonl.

From what I've read on here and in my own policy, yes, if you have one or more comorbidities (as defined by your insurance company, but usually high bp, type 2 diabetes, heart disease, or sleep apnea), then your BMI only needs to be 35+ to be approved. If you have no comorbidities that you know of, then get tested. Sleep Apnea is one that a lot of people have and don't know it. I have high BP, but went for the sleep study as well since I have some symptoms of sleep apnea, and it turns out I do have this as well.

If you have picked a surgeon already, I would check w/the insurance liaison(s) at your surgeon's office. They will probably have the experience and knowledge to know how to handle this situation. Sorry I am not more help than that.

I have Aetna and noticed that their clinical policy bulletin for obesity surgery (Obesity Surgery) is up for review on 2/12/2009. Not that far off. Should I be worried that they will change it against my favor. I have my BIG appointment w/the bariatric surgeon's office this Friday (2/6). Should I push to get all my paperwork together and submitted ASAP? I still have the physician supervised diet to complete, but Aetna will approve pending the completion of this diet if you submit prior to completing it. What do you think?

Thank you SO MUCH for your update. I'm so happy for you and happy for me too because this means I should be able to eventually get approved even if it takes many appeals. I haven't even submitted to insurance yet. I'm still getting some stuff together. Will probably submit in about one week after getting results from my sleep study back.

Well, first thing, definitely find out if you have any of the comorbidities because if you do, then you have met the qualifications and should be approved. Aetna requires a 3 or 6 month diet (details are in their clinical policy bulletin Obesity Surgery ) If you don't have any comorbidies, then I think you will probably get denied the first go-around. I'm actually in a very similar situation in that I have comorbidies and BMI of 38 right now, but my BMI went below 35 in 2006 and 2007 because I was on WW. But, I can show BMIs of 35+ for 2002-2005. I have not submitted to insurance yet (probably will in about two weeks - after my sleep study). But, I fully expect that they will deny me. Basically, from what I've read on here, the first go around w/insurance tends to be very unforgiving. If the insurance company can find ANY reason to deny you, they will. But, then there is chance for an appeal through the insurance company (where someone looks more closely as to why they are denying you and MAYBE they will approve you). Worst case, it goes to outside review which is the point at which I think both you and I would win our cases because then the approval/denial is based on NIH standards instead of Aetna standards. And, NIH says nothing about the history of obesity having to be in the last two years. In fact, that we are able to show that we could take significant weight off on our own (but without success at keeping it off) makes us ideal candidates for this surgery. Anyway, I will update here as I go along my journey w/this. And, I wish you all the best with this. I definitely think its worth pursuing. My mom got lapband just over one year ago and has lost 95 pounds. :->

I am no expert on this, but from what I've read on here before, I think you could just gain enough to get your BMI to 40 and then appeal w/the new weight. You are so close to a 40 BMI anyway, its silly they denied you. I mean you could probably 'gain' enough weight just by drinking a big bottle of water before getting on the scale or wearing some heavy jeans and a jacket. ;->

I wish you a speedy approval. BCBS seems to be one of the better ones as for approvals so I'm predicting good news from you in a few days. :->

This doesn't sound right to me that one would be covered and not the other. Did you get this documentation from your employer or the insurance company? I'm just thinking that maybe if you got it from your employer's HR dept, then maybe someone messed up and gave you outdated info (since banding used to be considered 'experimental').