Aetna Schmetna

[Christabel 0]

Two weeks ago I called my new insurance company to make sure VSG was covered - before I ever went to the informational meeting about any type of bariatric surgery, before I got my hopes up, before ANYTHING.

I went to the meeting, got excited, got down and got funky with the idea of VSG. I filled out the forms, I made the appointment for my first visit with the surgeon.

My first visit was today.

I got weighed in, measured, and then the assistant asked what type of surgery I was interested in. I told her VSG.

*crickets*

"Oh honey," she said. "Aetna doesn't cover VSG."

But they DO, I argued. They SAID SO when I CALLED THEM. They wouldn't lie to ME, would they?

"Way-ul, we'll just play like they're gonna cover it for today. You give 'em another call again tomorrow and let me know, and we'll see what happens."

Fur will FLY, Ladies and Gentlemen, if I have been lied to.

FUR WILL FLY.

[Christabel 0]

UPDATE

Shot down like skeet.

While the case manager nurse was very sympathetic and almost SURE it was covered at first, upon further review she found it wasn't.

I almost cried.

I was so dejected. I thanked her for her time and got ready to hang up the phone.

She said,"You mean you're just going to GIVE UP??"

I asked her what choice I had. I'm not going to have the band and told her why. I'm not going to do RNY and told her why. I told her the only option I was interested in was the sleeve and why. I told her about the arthritis in my knees and feet that make it hard to walk. I told her about the sleep apnea and the CPAP machine. I told her about the depression, the cyclical joint pain and fatigue that knocks me flat, and my family history with obesity.

She asked me again if I was just going to give up. I asked her what other alternative I had.

She suggested going through all the hoops necessary to be approved for bariatric surgery, no matter what kind, that my insurance requires. Currently it's a six-month diet, psych eval, behavior modification, etc. She told me the insurance is constantly under review and hopefully by the time I was done with all the pre-op work it would have changed.

So I stopped feeling sorry for myself. I'm being proactive. I'm taking her advice. I'll do what I have to do, and I'll hope things change between now and then.

And if they don't, THEN I'll sit in the corner and suck my thumb and eat hot fudge sundaes until I pop.

That's logical and sane, right?

[mrlddst 0]

Way to stay positive!

[mmcclure 3]

It's my understanding (could be wrong) that Aetna is going to look their bariatric surgery policy over on February 11th. Say a prayer that they approve the sleeve at that time. My daughter and I both want that surgery, as well. I don't know why it is taking so long for the insurance companies to approve it (although some of them are now) - it is cheaper, generally has less complications, better long-term results, etc. Of course, we ARE talking about insurance companies here - they always make sense, right?

[Christabel 0]

As of 2/12/10 there has been no change in the policy, however the case manager told me it still read "Next review date, 2/11/10" so I'm sure it just hasn't been updated yet. :lol0:

Has anyone heard anything either negative or positive through the grapevine?

[mrlddst 0]

No not yet...I googled the news for Aetna and the policy on the site still states the same thing.

[julester 16]

I went to the obesity bulletin as well and it still hasn't updated but a member on obesityhelp.com told me that Aetna is approving the sleeve now. She better not be lying because I got goosebumps and all! I'm going through the same thing as you...We will try to put our positive thoughts out to the universe together and hopefully it will return to us with a positive outcome!!! Keep me informed if you hear anything!

[mrlddst 0]

The jury is still out of that one. If medicare isn't picking it up than I don't think Aetna will. I was reading somewhere that they need at least 5 years of consistent sustained evidence that a WLS works before they will add it. I can't find anyone before 2006 who had the surgery

Just sent them an email asking them about any pending updates. Will post reply.

Edited February 17, 2010 by mrlddst
added info

[bigtex52 0]

I have Aetna as well. I asked the surgeon if he thought they would cover VSG early this year and he told me that Aetna is always the last to approve a procedure. They were with the band and RNYGB. He said it might be another 3 or 4 YEARS in his opinion. He has a lot of experience in WLS. He did the first band in Dallas when the FDA approved them.

I self paid and am glad for every minute so far, even though it is a bit of a fiscal inconvenience. Unfortunately, besides my physical rewards, Aetna is reaping big savings off of my expenditure!

[mmcclure 3]

Yes, but haven't they been doing this procedure as the first step in a two-part surgery for people with high BMIs for a long time? Seems to me that that could be used as evidence that it is safe and effective, especially since I read that a lot of those people lost enough weight that they decided not to do the second part of the surgery.

This is really bumming me out. My daughter and I really want and need this surgery but can't afford to pay out-of-pocket here in the States and she is adamant about NOT going to Mexico to have it done. And, it makes me nervous when I hear about people having complications and no one willing to touch them after they have had surgery in Mexico.

So depressing...

[thinoneday 445]

Is there any way you can self pay? I mean it's so much better that way. . I went for my seminar in October, visited with my doctor in November and had surgery in December. . it was so easy. . . i got a really good loan through my credit union at 3.7% and was financed for the whole amount. . . you may want to look at this route, at least you don't have to jump hoops for ever. . .

[mmcclure 3]

Ok, now I am totally confused. I called the member services number on my ID card and the person there told me that our coverage is actually NOT an Aetna plan, even though it says it is an Aetna company. Because it is a different type of plan/company, they don't follow the same guidelines and rules that Aetna does. She said that it doesn't matter what type of surgery we have done, it is covered up to a certain amount, with deductibles of course.

I'm afraid to be too excited about this until my surgeon's insurance coordinator calls to confirm. But, I am optimistic because this woman told me the same thing several times and even gave me a direct phone number for the provider to call to confirm. I told her that the insurance coordinator called before and was told something different and she said that, according to our file, no one has called (they keep track of every call) and that the coordinator probably called Aetna, not them.

Has anyone had this kind of insurance before and used it? Even though my ID card very clearly says, "Aetna" on it, it also says, "SRC an Aetna Company."

[Christabel 0]

I would be very leery of anything told to you by someone over the phone unless it was a case manager. I have to speak with a special pre-approval number (I learned this the hard way) in order to get the true information I need. As of today Aetna has still not updated the policy bulletin, and I found there are other policy bulletins that have not been updated that date back to the first of January so I'm not holding my breath.

In addition, I found out today that even if Aetna approves VSG, it still has to go through an approval process with my employer before it will be covered.

In the meantime, I am doing everything I can to just hang in and follow the regimen. Had the first of 7 nut and exercise meetings, and went through not one but two psych evals. The psych evals were required by the employer and could not be finished in one sitting due to length. Three different tests, one 384 questions long.

And so I plod along....:svengo:

[morethan 4]

Aetna has updated their site: This CPB has been revised to state that sleeve gastrectomy is considered medically necessary when criteria are met.

[Christabel 0]

MoreThan, I think I love you. Seriously. :tongue_smilie:

I'll be calling my insurance on Monday to check in again. Hopefully my employer will have also updated their policies. Cross your fingers!