worried about aetna!!

[chris1021 0]

hello to all

im new here and very new on my Lap Band journey. i attend my first seminar next Tuesday!! im very excited because i have read a lot on this forum and chatted with some amazing people who have been on their journey for quite some time..all these have had very different experiences but these people have one thing in common... THEY ARE AS HAPPY AS THEY HAVE EVER BEEN!! this makes me ever more excited and ready to feel and see the changes. dont take me wrong i am very much aware of the down sides to all of this such as physical challenge of not losing my way and the mental challenge which lays ahead. have read the risks, the concerns everything and to me, the risks are well worth it if the outcome is that i live a healthier life.

having said all that...

my worries lay in aetna. i have read the revised criteria for this surgery and to me it seems like that make it harder for people to get approved!! my bmi is 38.2 and that accompanies multiple morbidities however only few do aetna see as "severe" and of course the "servere" ones arent my problem. they dont even list the other morbidities that the Lap Band does.. wth!! was just wondering of those of you out there who have done this recently with aetna, how hard was it to get approved? :smile:

[Desiree1972 0]

don't know a thing about Aetna - sorry!

good luck

[Cocoabean 430]

Hi Chris, I don't have aetna, but I am not sure your post is clear, do you have the co-morbidities that aetna specifies? Or is it specific at all?

When I had my surgery, my insurance requirements were fairly clear, but had some wiggle room.

BMI 35-39 with 2 comorbities "such as" high blood pressure, sleep apnea, diabetes.

It is the "such as" that gives the doctors room for the wording in submitting to the insurance.

Mine now says "clinical criteria include but are not limited to..."

All companies are different. Do you have what yours says specifically? It can also vary from state to state. Have you spoken to Aetna to find out for sure what their requirements are?

Best wishes to you!

Note: I edited this post, because grammar is important and I had some typos. :smile:

Edited September 5, 2010 by Cocoabean

[chris1021 0]

i apologize for the mis-understanding, ill clearify.

criteria for Aenta is as follows:

A: bmi 40 or greater

b: bmi 35 or greater with conjunction with any of the flollowing severe co-morbidties

1-sleep apnea

2-coronary heart disease

3-hypertension

4-type 2 diabetes

thats it for adults.

my co-morbidities were

joint problems

back problems

depression

high cholesterol

stress urinary incontinence

at one time i dealt with gestational diabetes

and had my gallbladder removed due to stones

i have dealt with high blood pressure in the past

these are all the things that are one the Lap Band website for consideration of the procedure just not on Aetna's

i havent yet called Aetna, that will be on my to do list first thing tuesday :smile: i guess thats something i need to do first

anyways thanks for the support!! very much apperciated

[Cocoabean 430]

Hi Chris,

A few thoughts come to mind.

Have you had a sleep study? Many people have sleep apnea and do not know it.

Also, when is the last time you had your height checked? As we age we tend to shrink. Using a BMI calculator, if your height was 1.5 inches off, you'd make the 40 BMI where you'd not need the co-morbidities to qualify.

By the same token, what weight are you using? Is it a morning, naked weight? Or a fully clothed in jeans, sneakers, and outer wear, and at the doctor's in the afternoon weight? A half-inch shorter and 7 pounds heavier makes a BMI of 40, also.

I am not advocating gaining weight to qualify or putting fish-weights in your clothing. Just pointing out some things that could be different depending on when and were you are measured.

[chris1021 0]

wow thanks :smile: never really considered all that..actually when i weight its never at the same time or in the same manner,

the last time i was measured in height was...i think about 7 years ago and i have never had a sleep study before now never really thought i needed to

im going to look in to that as well

[Bryn 3]

Hi Chris!

I too have Aetna (PPO) and I called them a week ago and they sent via email, a list of what will qualify in order for them to approve the surgery. Just give that number on the back of your card a call, and the rep can help you. mine was very helpfull. unfortunately, i can't relay the email to you because it's secretly coded via aetna lol.

but yes, their main requirements is that

1) you have a BMI over 40

or

2) you have a BMI of at least 35 with any of the following co-morbidities:

--sleep apnea

--coronary heart disease

--hypertension (greater than 140/90)

--type II diabetes

aetna also requires (under my plan anyhow) at least 2 years of documented weight gains/loss and documentation from PCP. or any of the documentation from weight loss programs (jenny craig, ww, etc).

i heard from my doctor that aetna was one of the better insurances to have because generally we only have to undergo the 3 months of supervised diet/education vs. the usual 6 months others have.

so call that number on the back of your card!!! good luck!

[chris1021 0]

omg thank you so much Bry!! that actually makes me feel so much better

and good luck on your journey as well!!

[Loyalfriend 0]

Hi Chris, first you should call Aetna Customer Service and tell them that you need to check your contract for bariatric surgery. Make sure you plan does not exclude this procedure. Also, ask your doctor's office to give you the CPT billing code for the surgery and double check with your insurance carrier on the rules associated to receive approval for this code.

Aetna tends to be one of the insurance carriers that requires you to jump through alot of hoops to get approved so be prepared. That's why we call it a journey.

Visit your PCP and make sure he/she can document your weight progress over the past two years. Then document all your attempts at losing weight utilizing OTC pills, Jenny Craig, WW, etc.

This should give you a good head start on your road to insurance approval.

Good Luck!