Aetna pre-op weight loss required?

[Bypassjourney 88]

I am in month two of the three month process with Aenta insurance. It states in the clinical bulletin that you should be losing weight during this period to prove that you are willing to make the lifestyle changes necessary after surgery. My doctor's office does not require me to lose weight during this time but stated not to gain any either. My BMI is at 39.9 with sleep apnea as a co-morbidity. I have lost five pounds and I am sure I can lose a few more within the next month but feel like its a catch-22. I don't want to lose too much afraid they will say if I did that well, I can do it without surgery. But at the same time, want to lose enough that they see I am committed to this lifestyle change.

My question is did anyone lose or not lose weight prior to submitting the claim for approval and did that hinder or hurt your approval process with Aetna?

[Amanda 3.0 140]

Hello there, I am actually in the same boat as you. I am on my husband's insurance. His employer is actually self-insured (they pay all the medical bills, not Aetna) but they use the Aetna network and the Aetna reimbursement schedule. There is a third party administrator who writes the checks and sends the explanation of benefits, and does the approvals, all under the employer guidelines.

The employer actually has requirements different, and more stringent, than Aetna. I was required to be at 40 BMI (without comorbidities) at the start of the process and to lose 5% of my body weight during the supervised weight loss six month period. Losing 5% bumped me just below the 40 BMI which led to some upset as I was told by the plan administrator I would no longer qualify for the surgery.

I basically pointed out to the administrator that if one dipped below the 40 BMI during the six month period before surgery, and was then disqualified, the guidelines should really require a BMI of 42 or above to start the process. A person starting out with 40 BMI and required to lose 5% simply cannot qualify according to their own guidelines.

After checking with the employer, the administrator came back and agreed that it was okay to fall below 40 BMI during the six months.

However, this is the first year that the WLS has been offered, and so no one has gone through it yet! My paperwork has just been submitted to the administrator for approval, so I am hoping that this will become a reality.

I think if you lose weight conservatively (not too much), they can deny you with the stipulation that you lose more weight. However, if you drop a boatload of weight, and they deny you, what can you do?

Like I said, I have just had my paperwork submitted, and the decision-maker is not actually Aetna, but I hope it works out for the both of us. I will try to update here when I hear back.

Hope you are doing well!

[Khy 16]

I lost some weight while on the 3 month program with Aetna. I did not have co-morbidities so I was careful to keep my BMI right at 40. The insurance coordinator for my WLS said that they only send in my beginning weight and Aetna will use that. Aetna does want several years of documented weight. Anytime you go to the doctor and they weigh you... u can use that for for doucmented weight.

Khy

[Amanda 3.0 140]

I do have to prove a 5% weight loss with our plan, which is written by the employer, which is a very health conscience organization. I was able to get several years of documented weight from my primary care physician, which was perfect!

[longer-life 139]

Two things. Aetna ( and I think all insurances) go by the first weight. Also, my bulletin must be different than yours because mine did not say anything about having to lose weight to show a lifestyle change. I did decide to lose one pound a week and was approved in less than 72 hours.

Lastly, even if Aetna does not go by the first weigh (which I doubt), in my bulletin it says they cover people with a BMI starting at 35 with sleep apnea. So either way, it seems you could lose a ton a weight and not have any problems getting approved.

[LUCYCAT 6]

Hi I have Aetna as well. ( had my surgery on aug 1st) They made me go the whole 6 months. I've been told as long as you keep those once a month appointments with your PCP to "track" your weight loss they don't pay a lot of attention to how much you lose. I am pretty sure they do go by your start weight. I was careful not to gain- but careful not to lose so much that my BMI would be below the acceptible BMI.... just in case.

[Amanda 3.0 140]

Well my paperwork was sent to the insurance on Monday and I was surprised to receive my letter from the insurance administrator in my mailbox yesterday stating that I am approved!

I had given a copy of the insurance requirements (directly from the insurance policy) to the surgery coordinator at the surgeon's office, and we were sure to meet each requirement exactly.

Now, I just have to figure out the date and also decide if the first of next year would be better than the end of this year.

[klus263 9]

I also had Aetna with the self funded plan by more employer. They had stringent rules of 12 mos of pcp visit before approval but when I called Aetna, since they did the approval through their own precert department they required only the 3 or 6 month based on their bullentin. I did not show but only a few pound weight loss during the 6 months. I did have to show 2 years of being overweight-but hey I could have gone back almost 20 yrs if needed. I was 37 bmi with sleep apnea and diabetes. My surgery was approved with 24 hours of going to their precert doctor. I had my surgery Dec 1-just a year ago and could not be happier. Good Luck!

[ProudGrammy 8,322]

My dr. didn't require 5% weight loss. I wish he had because i decided to eat like there was no tomorrow Luckily I'm about 12 days pre-op and will try and lose what i can with the help of liquid shakes.

I have Empire and they take the weight that you started with. (I really think most places do that) . I heard the reason you are "requested" to lose some weight prior to surgery is to shrink the liver as much as you can pre-surgery. So worrying about "losing" too much , weight .... well that shouldn't scare you, like i said i believe they take that 1rst weight.

I will mention i am pre-op til 12/15/11 but i think these are the facts, I hope i'm right and that I didn't confuse anyone.

kathy

[Bypassjourney 88]

Thanks everyone for your posts. I go in for my last required visit on Thursday, 12/22. Then the insurance coordinator will submit the request to Aetna for approval. I have lost a few more pounds so hopefully they will see that as an effort and be satisfied with that. I am praying for a quick response because I am SO ready for my new life to begin!

Thanks so much for everyone's encouragement. This site is the best!

[CCWriter 19]

I was approved through Aetna, and they did require a 5 percent weight loss. I have co-morbidities of sleep apnea and high blood pressure too, and I'm not sure how all that factored in. They gave me a case manager (Paula), who has been checking up on how I'm doing. She was very encouraging before the surgery about how many of the people she works with get off their meds and CPAPs.

My co-pay turned out to be about $2,000 total for the hospital, surgeon, etc. Best Christmas present I've ever given myself.

CC

[longer-life 139]

I was approved through Aetna, and they did require a 5 percent weight loss.

This confirms the requirements are not the same for each policy. I have Aetna PPO and did not have to lose 5 percent.