I was approved by Aetna

[ozzy22 0]

I wanted to create this thread to help people understand what you need to do that have Aetna. I know every insurance policy is different, but with Aenta you generally do the same thing. I know when I started on my weight loss journey I was SO confused on EXACTLY what I needed. I was just approved this morning and I am beyond excited. This is what I did for the 90 day multi-disciplinary program

- You need documents showing you have had a BMI of 40+ for the last two consecutive years (or a BMI 35+ with co-morbidities) I went to my PCP and asked for these records myself and faxed them to the surgeon's office.

- You need to see a nutritionist once a month for three consecutive months (for example I saw my NUT once in November, once in December, and once in January.) You need to make sure your NUT faxes your information to your surgeon's office.

- You need to do some sort of exercise regimen through a qualified professional. My friend is an exercise therapist and we did Water aerobics every Tuesday and she filled out paper work telling what I did. Again, you need to do this for three months! I'm sure you could either get a personal trainer, go to yoga classes, go to Water aerobic classes, go to the gym at the hospital. Just make sure someone describes what you did and signs it.

- You need to log your food for 90 days (that is for the behavorial modification portion of what they're wanting). Also my surgeon's office said Aetna likes to see that you attened some support groups for behavorial modification. I attended two support groups.

- Also ask your surgeon's office if they have a pre-made template titled WLS MD Monitored program. You need to get that sheet of paper filled out at every doctor's appointment. It will have your current weight, blood pressure, and temperature. Then the doctor will just fill out what you talked about diet wise and behavior modification wise. I still have the template in my email address so if you want it please send me a message. My surgeon's office said this template wasn't absolutely necessary, it just makes Aetna approve you faster with a greater advantage of getting approved. My information was submitted to Aetna on a Thursday and I was approved by Tuesday.

That is all I did for Aetna alone. Of course your surgeon's office will have you do many other little appointments and all that good stuff. Hope this helps some people out with any questions about Aetna!

[lkcraig316 4]

You have me freaking out right now.

I also have Aetna and I am in month 2 of my three month prep. Nobody told me anything about a food log. I know about the nutritionist visits, the exercise physiologist visits, letter of clearance from my cardiologist, records from my PCP with a letter, etc. But they didn't say ANYTHING about the daily food log! That will put me back to square one if it's required. Unless I fudge a full month.

I am calling my surgeon's office first thing in the morning! ACK!

[ozzy22 0]

I'm sorry to freak you out! My surgeon's office never told me if it was 100% required or not. They just told me to do it because they were going to submit them. Also, honestly if I were you and they said you HAD to have the food logs I don't see why you can't fudge a little bit. I mean, it's just food logs. My surgeon's office told me that they don't really inspect them or anything.

[lkcraig316 4]

Thanks. I think I will call them tomorrow anyway, and then go ahead and start keeping a log beginning tomorrow. I could probably come up with most of what I've eaten for the last 30 days . . . or come pretty close.

Congratulations on your approval! I know you are SO excited!!!

[ozzy22 0]

Thank you! I am very excited yet really nervous at the same time. My surgery date is next week on Thursday!

[Melissal 0]

Hello,

Ozzy, and others with Aetna, do you mind if I ask you a question regarding the insurance approval? Did you have hypertension? I have the high blood pressure, but it's controlled under medication. Will they accept that if it's controlled?

Thanks!

Melissa

Oh, and btw, congrats on the approval and best of luck with your surgery. Keep us posted!!

[snoah 0]

Hi,

I'm looking into getting the sleeve but my Aetna plan does not cover the surgery. Do you mind telling me what type of plan you have with Aetna? I just don't know what to do. I can't afford to pay for it myself but I'm running out of options. Any information you could provide would be greatly appreciated.

Thanks

[former_vbg 198]

I wanted to create this thread to help people understand what you need to do that have Aetna. I know every insurance policy is different, but with Aenta you generally do the same thing. I know when I started on my weight loss journey I was SO confused on EXACTLY what I needed. I was just approved this morning and I am beyond excited. This is what I did for the 90 day multi-disciplinary program

- You need documents showing you have had a BMI of 40+ for the last two consecutive years (or a BMI 35+ with co-morbidities) I went to my PCP and asked for these records myself and faxed them to the surgeon's office.

- You need to see a nutritionist once a month for three consecutive months (for example I saw my NUT once in November, once in December, and once in January.) You need to make sure your NUT faxes your information to your surgeon's office.

- You need to do some sort of exercise regimen through a qualified professional. My friend is an exercise therapist and we did Water aerobics every Tuesday and she filled out paper work telling what I did. Again, you need to do this for three months! I'm sure you could either get a personal trainer, go to yoga classes, go to Water aerobic classes, go to the gym at the hospital. Just make sure someone describes what you did and signs it.

- You need to log your food for 90 days (that is for the behavorial modification portion of what they're wanting). Also my surgeon's office said Aetna likes to see that you attened some support groups for behavorial modification. I attended two support groups.

- Also ask your surgeon's office if they have a pre-made template titled WLS MD Monitored program. You need to get that sheet of paper filled out at every doctor's appointment. It will have your current weight, blood pressure, and temperature. Then the doctor will just fill out what you talked about diet wise and behavior modification wise. I still have the template in my email address so if you want it please send me a message. My surgeon's office said this template wasn't absolutely necessary, it just makes Aetna approve you faster with a greater advantage of getting approved. My information was submitted to Aetna on a Thursday and I was approved by Tuesday.

That is all I did for Aetna alone. Of course your surgeon's office will have you do many other little appointments and all that good stuff. Hope this helps some people out with any questions about Aetna!

I'm assuming you were a first time surgery approval? I also have Aetna PPO Choice and just learned today that I may have to go through a 6 mth supervised diet- but that's not what they told me when I first checked on this 2 months ago. There is a section for "Repeat Bariatric Surgery" that says nothing about that. Normally, I have found their customer service to be helpful, but when I called today to get clarification I just got the runaround saying they couldn't explain their policy bulletins. I would have to go through my Dr. to get explanation. I'm like, WTF...

Section III of this Aetna Policy Bulletin, for revisions- it says:

1. Repeat Bariatric Surgery:
   
   Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction, stricture, erosion, or band slippage.
   
   Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:
   1. Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   2. Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   3. Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments.

I qualify under Number 2. It doesn't say in the section about the supervised diet section if that is for first time patients or everyone. I can't imagine it would as I have complications from the original surgery.

Does anyone have any input on this?

[ozzy22 0]

I'm assuming you were a first time surgery approval? I also have Aetna PPO Choice and just learned today that I may have to go through a 6 mth supervised diet- but that's not what they told me when I first checked on this 2 months ago. There is a section for "Repeat Bariatric Surgery" that says nothing about that. Normally, I have found their customer service to be helpful, but when I called today to get clarification I just got the runaround saying they couldn't explain their policy bulletins. I would have to go through my Dr. to get explanation. I'm like, WTF...

Section III of this Aetna Policy Bulletin, for revisions- it says:

1. Repeat Bariatric Surgery:
   
   Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction, stricture, erosion, or band slippage.
   
   Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:
   1. Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   2. Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   3. Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments.

I qualify under Number 2. It doesn't say in the section about the supervised diet section if that is for first time patients or everyone. I can't imagine it would as I have complications from the original surgery.

Does anyone have any input on this?

Yes this was a first time surgery so I had to do a 3 month program. I never get the run around with Aetna, they are always SO good on telling me what I need. Aetna will be more informative than your surgeons office. Your surgeons office will just tell you to ask your insurance company questions.

[ozzy22 0]

Hello,

Ozzy, and others with Aetna, do you mind if I ask you a question regarding the insurance approval? Did you have hypertension? I have the high blood pressure, but it's controlled under medication. Will they accept that if it's controlled?

Thanks!

Melissa

Oh, and btw, congrats on the approval and best of luck with your surgery. Keep us posted!!

Hi there! I do not have hypertension but I am sure that is a good cause to get you approval.

[former_vbg 198]

Yes this was a first time surgery so I had to do a 3 month program. I never get the run around with Aetna, they are always SO good on telling me what I need. Aetna will be more informative than your surgeons office. Your surgeons office will just tell you to ask your insurance company questions.

Thanks. Your employer must have customized this part of the insurance because the policy bulletin says they normally require a 6 mth supervised diet. I even ended up speaking with a supervisor today in customer service and they said they are not allowed to advise what I am supposed to do, just to have the surgeon's office submit for a pre-certification, that I can always appeal if it gets denied. Boy...that was helpful. Not!

Tomorrow morning, I go in for an Upper GI/ End which needs to be done anyways. I have a Nut appt next Tuesday, had an appt w/my PCP today. I have an appt w/a head shrink next Tuesday- but he asked me what kind of testing I need done cuz there are many types of psych evals. I told him I wasn't really sure, that the policy bulletin doesn't say. I emailed the insurance gal at the surgeon's office tonight to see what she says. I don't see any reason to go through multiple visits and fill out some long test.

Depending on how many visits I have to go through for the psych eval, I could have everything I need to submit for a pre-certification by mid to late next week.

Then, wait.... My PCP is very much in favor of me having a revision and said he would put some documentation and a letter together to help show the medical necessity.

[nraeh 23]

I have the Aetna PPO but was not told about the "exercise regimen through a qualified professional" by my Dr's office or the NUT. Could it be that my BMI is way above 40 that that is not a requirement for me? Should I contact Aetna myself to find out exactly what is needed? I would sure hate to go my full three months and then not get approved due to the exercise regimen. I exercise myself on my own machine in my own home. Thanks for any advice on this.

[former_vbg 198]

I have the Aetna PPO but was not told about the "exercise regimen through a qualified professional" by my Dr's office or the NUT. Could it be that my BMI is way above 40 that that is not a requirement for me? Should I contact Aetna myself to find out exactly what is needed? I would sure hate to go my full three months and then not get approved due to the exercise regimen. I exercise myself on my own machine in my own home. Thanks for any advice on this.

Good luck w/getting the Aetna customer service to advise you. They will likely only refer you to their online policy bulletin. They kept telling me to work through my surgeon's office. See what the lady who does the insurance says, hopefully they will help advise you on that.

[MommyTawnie 3]

You have me freaking out right now.

I also have Aetna and I am in month 2 of my three month prep. Nobody told me anything about a food log. I know about the nutritionist visits, the exercise physiologist visits, letter of clearance from my cardiologist, records from my PCP with a letter, etc. But they didn't say ANYTHING about the daily food log! That will put me back to square one if it's required. Unless I fudge a full month.

I am calling my surgeon's office first thing in the morning! ACK!

If push comes to shove just finish out a 6 month supervised diet.. That's what I did and I was approved within 10 days.

I met with my PCP once a month for weigh in and a detailed description of what his recommendations are for exercise were, and he pulled a 2 year weight history for me.

I met 1 time with the NUT, and 1 time with the Pychologist.

I had a sleep study done which showed sleep apnea.

And last but not least my 1 consultation with my surgeon.

I had finished out my 3 months supervised diet only to find out I didn't do all I was suppose to do for the 3 months. If you ever get confused on what is needed call your insurance. I had Aetna when I had my surgery and like I said I had no problem getting approved..

[MissBarbara Jean 0]

Hi - I hope you get this. Your page was VERY helpful to me!

Do you still have th template for the Doctor? WLS MD Monitored program? If so please send it to me at bwells@charter.net

Thank you kindly.