Aetna Insurance

[illgeturhairdid 176]

Hi guys. I'm wondering what you all had to do to get Aetna do approve your surgery?

My surgeon has told me I will need to complete the following;

-2 year diet history

-3 consecutive monthly appointments with the nutritionist

-Pulmonary clearance

-Cardiology clearance

-Psych clearance

-Letter of medical necessity from PCP

-2 Support group meetings

-Pre op class

The surgeons office did not mention having to see my PCP monthly. Also, they said Aetna does not have a requirement to lose a certain amount of weight before surgery, just that I can't gain any.

For those of you with Aetna, does this all sound right or should I be questioning the surgeons office? When I called Aetna they said that the Dr. had to review the requirements with me.

Also, if you have Aetna and had VSG, once you had all of your documentation how long did authorization take? My last nutritionist appointment is 11/28 and I'm hoping to have surgery before 2012, think it is do-able?

[emily_0192010 168]

I have Aetna as well. The three month visit with the nutritionist will be reviewed by your surgeon (most likely) at the end and it should count as the PSWL (physician supervised weight loss). I had mine with a weight loss counselor twice a month for three months and then the surgeon signed off on it. I was required to provide a 5 year history, but I do that Aetna recently changed their guidelines to needing less. I didn't actually have 5 and I was approved.

The pulmonary clearance and the cardiology clearance and the two support group meetings were not required for me. Those may be things that your surgeon requires and not necessarily Aetna. My surgeon requested a bunch of bloodwork that went beyond the "standard" pre-op. That was something that he required but wasn't required for my insurance. I also had a pre-op class (though it wasn't called that exactly) and then a pre-op meeting with my surgeon.

So to me it sounds right. I am not yet sleeved but I will be on Monday It took two weeks (10 business days) for me to get my approval and I called and asked the status they day they approved it. So it probably would've been another couple days if I had waited for the notification to get my surgeon's office.

Technically the insurance has a maximum of 30 days to approve or disprove. So you might not make 2012. However I have never heard of Aetna taking that long before. It also depends on your surgeon's office. I would talk to them now and see if it looks like it will be a possibility. They should know or at least be able to give you a good guess. I know my surgeon's office schedules about a month out after you get approved. Every office is different though. They may even be willing to put you on the schedule now, conditionally waiting for your approval. I know if it ends up being 2013 that will not be great because the insurance year starts over and you will probably be required to pay your deductible again right? I was very happy when I was able to get mine done this year for that reason.

Good luck with everything! Oh, and I just want to stress communicating and talking and asking tons of questions to your surgeon's office because I assumed something and it ended up biting me in the butt and nearly cost me my surgery. So please, don't hesitate to double check anything.

[RickM 1,747]

Hi guys. I'm wondering what you all had to do to get Aetna do approve your surgery?

My surgeon has told me I will need to complete the following;

-2 year diet history

-3 consecutive monthly appointments with the nutritionist

-Pulmonary clearance

-Cardiology clearance

-Psych clearance

-Letter of medical necessity from PCP

-2 Support group meetings

-Pre op class

The surgeons office did not mention having to see my PCP monthly. Also, they said Aetna does not have a requirement to lose a certain amount of weight before surgery, just that I can't gain any.

For those of you with Aetna, does this all sound right or should I be questioning the surgeons office? When I called Aetna they said that the Dr. had to review the requirements with me.

Also, if you have Aetna and had VSG, once you had all of your documentation how long did authorization take? My last nutritionist appointment is 11/28 and I'm hoping to have surgery before 2012, think it is do-able?

If you dig through the Aetna website you can find their latest WLS policy bulletin on what is required - it's in reasonably plain English - or your surgeon's insurance coordinator may be able to lay their hands on one. When I went thru this earlier this year I needed either a 6 month Dr. supervised diet/exercise program or a 3 month program thru the surgeon (which my doc doesn't do.) I did the 6 month program with my PCP with a couple of visits with his associated nutritionist. I didn't get in monthly dr. visits as implied in the policy bulletin - scheduling issues made it more like 4 visits over the 6 months. I'm not sure about the 2 yr diet history (perhaps weight history is what they mean?), I didn't supply it specifically, but the data is in his records that were submitted.

The pulmonary and cardiac clearances are requirements of your surgeon depending upon your medical history (I did neither); the support group meetings, pre-op classes and psych evaluation are likewise your surgeon's requirements, but are typical.

Aetna is notoriously slow in approvals, but they shocked the insurance coordinator by approving within a week or so (though they are still dragging their feet on paying the surgeon's fees after 4 months)

I didn't lose any notable weight during the 6 month period, but continued my long term stall (which is why I needed the surgery - hello!) I actually gained some in the time between approval and the surgery with the serial last suppers out while doing all the requisite pre-op med appointments.

[bjstrans4mation 21]

Hope my answers help you---I have Aetna as well:

-2 year diet history - I just gave my surgeon my history of dieting over the past few years

-3 consecutive monthly appointments with the nutritionist - I only had to have 2 visits with the nutritionist

-Pulmonary clearance - sleep study required - Yes

-Cardiology clearance - Yes - this happens as a part of my pre-op with my PCP

-Psych clearance - Required 1 visit

-Letter of medical necessity from PCP - Will get once approved by Aetna

-2 Support group meetings - Not required for me

-Pre op class - not require for me

*I had to have 3 monthly meetings with my surgeon

*Had to have extensive blood work

*Gasro testing was a requirement - but since I just had my gallbladder removed--I just had to get clearance

***All of my paperwork was submitted to Aetna 10/12. Aetna contacted my surgeon's office 10/17 for information. I called yesterday -my status is pending. I called today - my status is pending. But my surgeon has requested approval by 10/24. Scheduled to be sleeved Nov 2nd----just need the auth. code from Aetna. The customer service Rep at Aetna told me not to worry--I'd have my in a few days!!!!!! I am so positive about this outcome.

Hope this helped

Blessings2u

bj

[ITSMEMRSJ 3]

Hi I also have Aetna

-2 year diet history - NO. 2 year weight history of at least 40 BMI

-3 consecutive monthly appointments with the nutritionist - YES. This was done through the Bariatric center

-Pulmonary clearance - YES.

-Cardiology clearance - YES, Stress test & Echo

-Psych clearance - YES.

-Letter of medical necessity from PCP - YES

-2 Support group meetings - NO.

-Pre op class - NO.

I also had to have an Endoscopy, Sonogram of abdomen, Chest Xray, 2 EKG's, and lots of bloodwork. It took about a week for them to approve.

Good Luck!