New to the whole process, Aetna, What can I expect?

[tonid2328 24]

Hello Everyone, I am completely new to the whole process of sleeving. To let you know a bit about where I am at, I have just had my first visit with the sergeon who has explained to me how much the surgery will help me personally and that his staff would help me with the remainder paperwork. I have had blood work done, and was informed that I would need to go through a 90 day process with a dietician, and since my BMI was 42, I will only need pre-op routine exams, (ekg, xray, etc) a eval from a psych, and afterwards my paperwork will be submitted to Aetna for approval. I have checked with my insurance and saw that I do meet all the criteria for the procedure and that the steps the physician told me were accurate. What I need to know is what can I expect to happen during the psych eval, the nutrition consults, and possibly a time frame of how long it takes once I have completed the required steps as listed above. Your input is greatly appreciated.

[Takingcontrol 467]

Not sure, I have Aetna & had to do 6 month nutritional diet program before approval. Psych eval is really only to make sure you know this is not a miracle cure...you still have to maintain control over your eating. I know of 3 people who have Aetna & had this procedure, we were All denied the first time, but appealed & addressed everyone of their issues & were approved. Good luck...it's just a process, but you will get thru!

[tonid2328 24]

Thank you for replying first of all Taking control, I do have a question for you: what was the bmi you listed when you received your denial the first time, and how do I make sure I cover all the angles just in case the first time around? The doctor that I have has worked numerous times with Aetna and has also performed the same procedure on two of my co-workers who both had the same insurance as I ( which is why I chose this doctor), but our circumstances are a lot different. they didn't have the bmi numbers 40 and up, but they had the other issues that went along with obesity. (sleep apnea, Hypertension) I guess i am just putting too much into this but I wanted to know from people who have my scenario.

[Takingcontrol 467]

I had over 40 bmi, but no other medical issues....which was one point in their denial letter. I wrote my own letter back to the insurance disagreeing...I DID have high cholesterol, which has been proven to lead to heart issues & I have a huge Famiky history of heart issues & diabetes! I just pointed that out to them, the people at my surgeons office didnt include that in the first request! Just check & see the requirements & make sure there all addressed. & if for whatever reason they deny you, they will state specifically why...then just go down the list & address every issue.

[gingerRN 81]

Get everything in writing from aetna!!! 5 days after my surgery I got a rejection letter. Luckily they are my secondary! I was mad because I jumped thru all their hoops that my primary insurance didn't require. On the phone they said I was accepted, in writing it was a different story.

[Dalola 12]

My BCBS insurance required 6 mo of weight loss, monitored by monthly doctor appts, with a set weight goal of at least 10 lbs. My BMI was 35 to start. I just qualified. Also had to go to physc. eval & an exercise class. I lost the weight on time but 6 mo turned into 9 mo getting all the appts to meet all the parameters, then having the doctor dictate a letter to BCBS confirm I had met all the prerequisites. I then had a one day marathon of tests and appts at the hospital before surgery. Surgery was then finally scheduled for a month later. Long haul! I am 6 wks post op. No regrets. Feel good. Down 2 sizes and dropping. Do exactly what they tell you. Day of surgery and after - WALK! It makes a huge difference in how rapidly you recover. Helps quickly eliminate the pressure from the surgery. The ones that did not walk remained uncomfortable. I was fine. Remember this is not a free pass to eat whatever you want and not gain weight. It is only a tool to control your appetite, therefore your temptations. You will still have to avoid the things and quantities that got us in trouble in the first place. It is just much much easier now. A friend has not changed her eating and drinking habits from her original lifestyle and gained back most of the weight she originally lost, a couple years later. What a waste! She is working her way back on track now. Diligent healthy choices will always be required for success. Good luck! You have made a huge decision to grab control of your life and health. I am thrilled I did. Hope you will too.

[cygnusatratus 73]

My docs explained that Aetna requires 3 calendar months of you meeting with dietician AND primary care about weight loss. (1 visit to each in each calendar month). It was just over 60 days for me because I squeezed in first visits at end of August. They require documented proof of weight from physician over past 2 years. They require a letter of medical necessity from pcp. I got approved within days with that formula.

[trujiyi 9]

I have Aetna as well and I had to prove that I was on a medically supervised diet for 6 months for within the last 2 years (which I had been cause my PCP had prescribed adipex for weight loss). I also had to do 3 months with a nutritionist, a psych evaluation and meet with an exercise physiologist. I did all of the above requirements (I have been in the process since July) and had my file submitted. The insurance company came back and asked if I had taken a sleep apnea test, which I hadn't, and was told I had 2 weeks to get it done or my file would be closed. I scurried to get an appointment at a sleep center only to find out that I had to pay $1,700 out of pocket to get it done (deductible + 20% out of pocket cost). I was completely discouraged and told the surgical coordinator to forget it. She said that she would call and see if they could put the file through without the test. They did and the next day I got a call that I had been approved... Woooo hoooo... Surgery is scheduled for Feb 14. Go through the process and make sure you do all the steps. After that leave it in God's hands.

[tonid2328 24]

Thank you all for responding. I have an update. I took all comments and your advice into consideration and here is where I am. I have both my nutrition and psychologist appointments scheduled to begin in Feb. I have since seen my PCP and learned that I have high Cholesterol and am a borderline diabetic. I have been prescribed Metformin for that. I was told by my PCP that those two co-morbid conditions may also aid in getting an approval from Aetna, so it appears that I am on track with what you all have explained to me. I realize that those conditions are good for insurance sake, but to know that I really really need a major change or risk other major issues makes me that much more motivated to have this procedure because I want to continue living and being there to see my children grow.

Thanks to you all for sharing your story with me, I know that I am on the right track for me!! I will continue to keep you all informed if you wish, and will continue to check back with the forum for support. Again Thanks to all of you.

[mark! 449]

I have Aetna, and they were a blessing to me versus who I had before. Aetna required a 3 month nutrition/Dr meeting, once a month, a qualifying BMI OR 2 comorbidities, along with 2 years, documented weight showing I've been overweight for that amount of time, I provided a 5 year printout from my PCP showing my weight fluctuating up and down for that period.

I'm not sure what the psych will be for surgery, for the fire department I used to work for and the police department I currently work for, it was basically to make sure your mind wasn't scrambled and that you had some form of common sense, and showed no signs of depression, etc. The test took forever, and the Dr was decent, but it wasn't anything crazy or major in my opinion.

Nutrition consults for me where 3 months of the nutrionist telling me what we should eat, and what we should do in order to lose weight, basically everything I'd previously tried, with little/no success, to lose weight. There were a few meetings that referenced post surgery diet, those were informative.

Aetna approved my claim in 5 business days after getting the paperwork to pay for my surgery, I'll pay a $4750 copay, everything else medically will be paid for $100 since I'd have met my deductible.

I have my stomach exam thing left, pre op meeting with the doctor, and pre op meeting with the hospital until my surgery, which will be Feb. 26th. Good luck with everything, and trust the nurses and such at the Drs office for getting the paperwork filled out right and such for the insurance company. I was so stressed about getting approval, and the nurse who did my paperwork was very, very good at working with insurance companies and making sure all our ducks were in a row before submitting the paperwork for approval.

[TrophyWife 11]

I have Aetna also and just posted a post on my insurance frustration. Long story short. I lost some weight a few years ago and it dropped my BMI to 35 and after a injury gained back some of it and now am at 46, my highest is 51BMI. Well found out today that I am pre diabetic, and also may be denied because during my 2 years of weight history mine fell into the end of my lowest weight and shows that even though I have been heavy for 25 years, I currently have not be fat long enough...awesome. We're hoping to not get denied, because I have completed everything and have 60 days left of 3 month supervised diet. Im ready to go and this just makes me sick to my stomach. Hope everything goes well with your claim and it goes through will help raise my spirits

[cygnusatratus 73]

may be denied because during my 2 years of weight history mine fell into the end of my lowest weight and shows that even though I have been heavy for 25 years, I currently have not be fat long enough...awesome.

My understanding is that Aetna needs one weight per year for the two years. Just have your Doc report your highest weight for each of the last two years.

Also, don't forget that Aetna seems to have a hidden requirement for a letter of medical necessity from your primary care. My surgeons office panicked about mine and my PCP delayed that forever until I almost missed my surgery date...

[mark! 449]

I didn't have to send in a letter of medical necessity, but each plan is different, even 2 people on the same plan number could potentially have different coverage.

[Shawn Morrison 71]

I had a great experience with Aetna. Other than having some extra hoops to jump through than some of the other people that I have read about it was great. I had to see my primary care, my dietitian, my psychologist and my exercise guy for 3 months each. Once that once done I received my approval on the first try after only 1 week of waiting. Very nice group.

[tonid2328 24]

Hello everyone, and thanks again for sharing your stories with me. All of them are very insightful. Here again I have another update. I have since seen the Psychologist and was cleared from that aspect. (Mark that test was extremely long to me too!) Either way it is good that I am not crazy for wanting this procedure according to the psych (Smile). Now we are on to the nutrition portion. I have yet to see the nutritionist but have an appointment at the end of this month. The more I do and get done the more I get excited about turning my life around for ME!! Now, this may be a bit petty, but I want to know what you all think. Here goes.... I want to take my children( 3 teen boys 1 pre-teen girl) on a much needed cruise this summer....but I know that I am working towards having this surgery possibly around May or June at the earliest if things go well. With school starting in Aug. would it be better to have the surgery before the trip or after? I don't want to be feeling miserable and not be able to enjoy doing things with my kiddos, but I also don't want to waist any more time being overweight than I already have. How would you go about this?