Anyone been approved by Aetna?

[ozzy22 0]

I know each insurance policy is different, but I am just wondering if anyone here has been approved by Aetna. Please read what I've done for my requirements and let me know if you think it's sufficient or not:

- saw psychologist in November

- saw nutritionist once a month for 3 months. Once in Nov, once in Dec, and once in Jan.

- saw exercise therapist once a week for three months. She also documented what I did everytime I can in and worked out and documented our talks about nutrition.

- filled out three months worth of food logs

- went to two WLS support groups

- I have 5 years of weight history, two years being morbidly obese

- Upper GI appt.

- EKG and chest x-ray done

- lab work done

- pulmonologist done

That's all I can think of at the moment that I've done. Please let me know what yall did and if what I did sounds like it should get approved.

[DougNichols 124]

- saw nutritionist once a month for 3 months. Once in Nov, once in Dec, and once in Jan.

Looks right, except for this one. Wasn't it 4 appointments? Mine was at least.

[ozzy22 0]

I'm not really sure. My surgeon's office really doesn't know the question to that either. I know a lot of people that had Aetna that said they saw nutritionist once a month for three months. Hmm, not sure. I will call the insurance company today and see if they can tell me what they're wanting.

[DougNichols 124]

Yeah I'd double check everything with Aetna.

[6kiddos 18]

1. Here is Aetna's Clinical Policy for bariatric surgery. If you go to their website and search for "bariatric" you will find this. You have the option of 3 month (more intense) or 6 month (PCP, etc) I personally did the 6 month with my PCP, 2 yr weight history (using 1 gyn appt for 2008 and gym record for 2009), nutritionist, psych eval, pulmonologist, and cardiologist. I was approved just fine. =) Good luck!
   
   
   
   
   
   
   
   Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Sleeve Gastrectomy, Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures:
   
   Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic sleeve gastrectomy, open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met.
   
   Selection criteria:
   
   
   1. Must meet either 1 (adults) or 2 (adolescents):
      
      
      1. For adults age 18 years or older, presence of severe obesity that has persisted for at least the last 2 years (24 months), defined as any of the following:
         
         
         1. Body mass index (BMI) (see appendix) exceeding 40; or
         2. BMI greater than 35 in conjunction with any of the following severe co-morbidities:
            
            
            1. Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in CPB 004 - Obstructive Sleep Apnea in Adults); or
            2. Coronary heart disease; or
            3. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management); or
            4. Type 2 diabetes mellitus

            [*]For adolescents who have completed bone growth (generally age 13 in girls and age 15 in boys), presence of obesity with severe comorbidities:

            1. BMI exceeding 40 with one or more of the following serious comorbidities:
               
               

               [*]BMI exceeding 50 with one or more of the following less serious comorbidities:

               1. Medically refractory hypertension; or
               2. Hypertension; or
               3. Dyslipidemias; or
               4. Nonalcoholic steatohepatitis; or
               5. Venous stasis disease; or
               6. Significant impairment in activities of daily living; or
               7. Intertriginous soft-tissue infections; or
               8. Stress urinary incontinence; or
               9. Gastroesophageal reflux disease; or
               10. Weight-related arthropathies that impair physical activity; or
               11. Obesity-related psychosocial distress.

               [*]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):

               1. 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 at each visit. 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 (within 6 months prior to surgery), member must participate in organized multidisciplinary surgical preparatory regimen of at least three months (90 days) 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:

                  1. Behavior modification program supervised by qualified professional; and
                  2. Consultation with a dietician or nutritionist; and
                  3. Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen at each visit. (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.); and
                  4. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
                  5. Program must have a substantial face-to-face component (must not be entirely delivered remotely); and
                  6. Reduced-calorie diet program supervised by dietician or nutritionist.

                  and[*]For members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, pre-operative psychological clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and postoperative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.

                  [*]

            2. 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; and
            3. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote); and
            4. Nutrition and exercise program(s) must be for a cumulative total of 6 months (180 days) 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.)
      2. Clinically significant obstructive sleep apnea; or
      3. Type 2 diabetes mellitus; or
      4. Pseudotumor comorbidities.

[ozzy22 0]

Thanks 6kiddos. Yeah I've read that on their website before. I am just not sure how many times they're wanting you to see the nutritionist since that bulletin doesn't specify. How many times did you end up seeing the nutritionist?

[klus263 9]

I did the 6 month wit PCP. I was only required to do just one time with the nutritionist. If you are on the 3 month plan, it has to be 90 days from the first to last appointment which would be one more more for you. I was approved within 24 hours with Aetna.

[Jebellah 0]

I think it really depends on your plan. I was denied by Aetna (and denied 2 appeals) with a BMI of 47 and co-morbidities. They said it was specifically excluded from my plan (***) and not even my Primary Care or Surgeon's letters could sway them. Hopefully you will have FAR better luck but I would call someone and ask them to look specifically at your plan and tell you exactly what requirements they have. And make SURE you document the date/time/who you spoke to!

Best of luck!

[former_vbg 198]

I think it really depends on your plan. I was denied by Aetna (and denied 2 appeals) with a BMI of 47 and co-morbidities. They said it was specifically excluded from my plan (***) and not even my Primary Care or Surgeon's letters could sway them. Hopefully you will have FAR better luck but I would call someone and ask them to look specifically at your plan and tell you exactly what requirements they have. And make SURE you document the date/time/who you spoke to!

Best of luck!

I'm sorry to hear this. So, are you able to do the self-pay route then? I feel fortunate that I have Aetna, they seem to have a rather generous WLS part of their coverage. I know that my revision will be covered when I decide on the right doctor for me. Although, I don't take anything for granted with the changes with the Healthcare reform- who knows what benefits will be cut next year so I will get the revision done this year one way or another.