Aetna

[Livebyfaith88 0]

Hello my name is Melissa this is actually my first thread on here. I'm 24 years old. My whole life I've suffered from obesity and my weight has constantly been a yo-yo. I started my journey to get the Lapband in December I saw my dr in northern va and we decided the band was the best option for me. My BMI has always been close to 40 or over my entire life I've seen my primary care for 10 years now and have always maintained an ideal 'overweight'. Well Aetna required me to do 4 nutrition visits which in the beginning they said it was 3 since I started in December when January came they all of a sudden required 4. I had my psych Eval and passed that. My weight in 2010 was 215 and in 2011 I was trying to lose weight and my weight was 190 in January those are the only documentations I have for my 2 year weight history. Also in 2011 I got pregnant with my daughter at the end of feb so for the rest of the year I was pregnant and of course gained weight probably about 50-60 pounds and these documentations of weight are not eligible for approval since I was pregnant. So after all these hard months of working my way to approval they send everything in and tell me that the only way I would get approved is if I get a sleep study and have sleep apnea. Even if I have the test and I don't have sleep apnea they won't cover it they told me today. Mind you at this point since I've had my daughter I'm not 238 pounds. So the only way to approval is if I have sleep apnea. At this point I'm so discouraged with this whole process. I feel like once I get one thing done there is another issue and so forth. I've wanted this more than anything especially for my daughter I don't want her following in my foot steps I wanted this new life not only for me but for her too. Not only am I frustrated with Aetna but I'm frustrated with all the time and money spent on this journey just to be told no. I'm going to get the sleep study done but I feel as of this won't do any good since I've never had any issues that I know of in the past. Just looking for some encouraging words or if anyone has gone through anything similar with Aetna the only problem they have is that one office visit weight of 190 which I understand but my dr has written a recommendation letter stating I've tried many things for the last ten years and they still are only going to approve me ONLY if I have sleep apnea. :-(

[labwalker 1,177]

Did they always have a clause requiring a co-morbidity, such as sleep apnea?

Something doesn't add up here. You were eligible before coming pregnant, and afterwards you have given birth, and I sure the weight hasn't gone down from where it was when you first applied. I think you need to call Aetna and to speak to someone who handles the bariatric surgery approvals.

[stept04 465]

My journey to get WLS as been almost 9 yrs. I started out with trying to get gastric by-pass when my husband was in the military. But, I did not have any health conditions that supported me having surgery so they would not pay for it. Next, I had insurance that would pay for it but by the time I got ready to do it, my husband lost his job. His next job they would'nt cover me. Then I just gave up on it, thought it would never happen. Then one day something made me go read the coverage booklet,and low and behold they changed and now they cover it. So now I'm scheduled to get banded May 28th. That was just the short version. Nine years is a long time,and every one around me was getting banded it su&^%ked. But, once I let go and let god so to speak it actually ended up going by fast now that I look back. Any way I quess I'm saying It's not over till its over. I'm getting banded, unless something happens .Then will just see what happens. Don't give up it can still work out somehow. Good Luck

[Livebyfaith88 0]

Did they always have a clause requiring a co-morbidity' date=' such as sleep apnea?

Something doesn't add up here. You were eligible before coming pregnant, and afterwards you have given birth, and I sure the weight hasn't gone down from where it was when you first applied. I think you need to call Aetna and to speak to someone who handles the bariatric surgery approvals.[/quote']

Well I guess the 190 weight they said my BMI was under 40 which is what they are using against me to not approve and then my post pardon office visit from my obgyn I was 240 and they said they can't use that since I just had a baby -___- they keep giving me the run around it's so frustrating & I spoke with a nurse today for Aetna and she explained all of this to me. So basically my 2010 visit is fine but my 2011 visit isn't and I was mostly pregnant that year.

[Livebyfaith88 0]

My journey to get WLS as been almost 9 yrs. I started out with trying to get gastric by-pass when my husband was in the military. But' date=' I did not have any health conditions that supported me having surgery so they would not pay for it. Next, I had insurance that would pay for it but by the time I got ready to do it, my husband lost his job. His next job they would'nt cover me. Then I just gave up on it, thought it would never happen. Then one day something made me go read the coverage booklet,and low and behold they changed and now they cover it. So now I'm scheduled to get banded May 28th. That was just the short version. Nine years is a long time,and every one around me was getting banded it su&^%ked. But, once I let go and let god so to speak it actually ended up going by fast now that I look back. Any way I quess I'm saying It's not over till its over. I'm getting banded, unless something happens <img src='http://www.bariatricpal.com/public/style_emoticons/<#EMO_DIR#>/smile.png' class='bbc_emoticon' alt='' />.Then will just see what happens. Don't give up it can still work out somehow. Good Luck[/quote']

Aw that's awesome news ! I'm very happy for you ! Thanks for the encouraging words man I tell you I've pretty much been in tears this whole day since I spoke with stupid Aetna LOL it just gets so discouraging at times and me and my friend started this process together and her insurance didnt even ask for a weight history I'm like really!! Lol this would happen to me ! But I was prepared for obstacles but not to get to the end and be told no after all the work I did to get here.

[DELETE THIS ACCOUNT! 12,703]

What is your current BMI? How many pounds are you from being at 40?

[Livebyfaith88 0]

What is your current BMI? How many pounds are you from being at 40?

I'm over 40 right now bc I'm like 238 pounds I think it's 42 or 41 but in 2011 in January I was apparently 35.9 bc I weighed 190 so that's what they are giving me a hard time on approving :-/

[DELETE THIS ACCOUNT! 12,703]

I'm over 40 right now bc I'm like 238 pounds I think it's 42 or 41 but in 2011 in January I was apparently 35.9 bc I weighed 190 so that's what they are giving me a hard time on approving :-/

Ugh that is ridiculous!

I would ask if there is any other co-morbidities they will consider, like high blood pressure, that you might meet.

I would also ask them how long you have to sustain a 40 BMI before they'll cover it. I know this sucks but then at least you can be careful to maintain your current weight long enough for them to cover it.

I'll cross my fingers!

[Livebyfaith88 0]

Ugh that is ridiculous!

I would ask if there is any other co-morbidities they will consider' date=' like high blood pressure, that you might meet.

I would also ask them how long you have to sustain a 40 BMI before they'll cover it. I know this sucks but then at least you can be careful to maintain your current weight long enough for them to cover it.

I'll cross my fingers![/quote']

Well since my medical records state I don't have diabetes or high blood pressure my only way out is a sleep study to prove that I have sleep apnea which I doubt I do bc I have never experienced any symptoms that I know of I guess it won't hurt to do the test but I'm getting so frustrated and discouraged that I want to give up haha and just try to work on losing the weight myself which I have failed numerous times haha but I guess this is my wake up call if I don't get approved

[50for50 72]

10 months ago when I started the approval process my Aetna policy required a BMI of 40 or 35 w co morbidities AND 6 months of a medically supervised diet. I completed the 6 months and I had a 40 and high blood pressure. Aetna denied me twice - the first time saying my blood pressure was controlled so it wasn't medically necessary. The 2nd time, on appeal, because they said I couldn't document 3 years of being obese. My Dr scheduled a "peer to peer" review next. Inexplicably they reversed their decision a few days before the scheduled review. No problems since then. Moral of the story is to persevere - they hope you go away if they throw obstacles in your way.