Aetna...What did you do to get approved?

[dede0314 356]

Hello,

I am in the process of starting my journey. I have my first meeting with the surgeon on Sept. 26. I have Aetna POS I am really nervous that they are going to deny me. Can anyone who has gotten approved by aetna tell me in detail what they did?

[Mike4132 256]

My paperwork was submitted today by my Dr's office and I have Aetna Choice POS II. I will let you know how it goes.

They are submitting:

-documented BMI of 40 with sleep apnea as a co-morbidity

-psych eval

-nutritionist visit eval

-6 month weight loss trial results

-2 years of height /weight info showing obesity levels of weight

-letter of medical necessity (from the weight loss trial Dr.)

I hope all goes well but we'll see. My Dr office claims Aetna is usually easy to work with for approvals. They are estimating 2-4 weeks for a decision. I'll be calling Aetna on Monday to see if they received the info.

[facorsig 36]

Documentation required was same as Mike. Approval needed an entire month. Seems there was some delay over my two year weight record because it came from overseas.

[jessiquoi 623]

i also have aetna POS, and only need a 3 month supervised weight loss bc it is done by my surgeon and not my pc. i called aetna and had them send me the requirements... they require no net gain during the supervised weight loss period.

[dede0314 356]

@@jessiquoi Did you get approved already? So all you did was meet with a nutritionist for three months?

[jessiquoi 623]

no no no!

first, i am not approved. i have my last weighin tomorrow.

i've also had about a gazillion tests and procedures because of my age and comorbidities as well as requirements.

here is the excerpt from the looooooooong document that refers specifically to vsg. hope this helps:

Policy

Note: Most Aetna HMO and QPOS plans exclude coverage of surgical operations, procedures or treatment of obesity unless approved by Aetna. Some Aetna plans entirely exclude coverage of surgical treatment of obesity. Please check benefit plan descriptions for details.

1. 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 aged 18 years or older, presence of persistent severe obesity, documented in contemporaneous clinical records, 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., person meets the criteria for treatment of obstructive sleep apnea set forth in CPB 0004 - Obstructive Sleep Apnea in Adults); or
         2. Coronary heart disease, with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure or prior myocardial infarction); or
         3. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes); or
         4. Type 2 diabetes mellitus
   2. For adolescents who have completed bone growth (generally age of 13 in girls and age of 15 in boys), presence of obesity with severe co-morbidities:
      1. BMI exceeding 40 with one or more of the following serious co-morbidities:
         1. Clinically significant obstructive sleep apnea; or
         2. Type 2 diabetes mellitus; or
         3. Pseudotumor comorbidities
      2. BMI exceeding 50 with one or more of the following less serious co-morbidities:
         1. Medically refractory hypertension; or
         2. Dyslipidemias; or
         3. Nonalcoholic steatohepatitis; or
         4. Venous stasis disease; or
         5. Significant impairment in activities of daily living; or
         6. Intertriginous soft-tissue infections; or
         7. Stress urinary incontinence; or
         8. Gastroesophageal reflux disease; or
         9. Weight-related arthropathies that impair physical activity; or
         10. Obesity-related psychosocial distress.
2. Member has attempted weight loss in the past without successful long-term weight reduction; and
3. Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multi-disciplinary 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:
      1. 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. Records must document compliance with the program; the member must not have a net gain in weight during the program. 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
      2. 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
      3. 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 3 consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of 6 months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.)

or

1. Multi-disciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multi-disciplinary surgical preparatory regimen of at least 3 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 multi-disciplinary surgical preparatory regimen at each visit. Records must document compliance with the program; the member must not have a net gain in weight during the program. (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 multi-disciplinary 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

1. 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 post-operative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.

[dede0314 356]

Thanks for the info

[Ladiec2 74]

Hello: I too have AETNA and am about to begin the process. I went to a seminar last year In Richmond, VA (Oct 16) and only have a couple of weeks to make an appt. with that Dr. so I won't have to sit thru the seminar again. I participated in 2 Webinars this week and I actually like one of those Drs. better. So I think I'm gonna make an appt with the one at INOVA Hosp. in Fairfax. I am very excited and I hope AETNA approves my surgery. My BMI is 35.2 (borderline) withSleep Apnea and Rheumatoid Arthritis. I've tried everything over the past years and I just keep gaining it all back and then some. So good luck to you with AETNA!

[brown eyed gal 59]

Mine was same as Jessi. I just found out I was approved. I have my surgery October 22nd! They submitted to insurance on Friday and I found out Tuesday I was approved! I'm having RNY.

[jessiquoi 623]

that's awesome that it was so quick, @@brown eyed gal! i was just submitted this week and am waiting to hear. getting really REAL!

[nbw1220 58]

Just had my info submitted monday! I had to do everything mentioned as well. 3 month supervised diet, met with NUT, psych, etc and had a bunch of tests done. Found out I had sleep apnea during testing. It's a lot of appointments.. But the time flew by fast! I lost a total of 25 lbs with the diet and exercise. ..Now I'm just waiting lol. I think this is the worst part!

[Ladiec2 74]

i also have aetna POS, and only need a 3 month supervised weight loss bc it is done by my surgeon and not my pc. i called aetna and had them send me the requirements... they require no net gain during the supervised weight loss period.

Jessiquoi: what did you do or say to be able to get the surgery in the 3 month period. I too have AETNA and they listed the 3 or 6 month plan. I didn't understand the difference. I want to see if I qualify for the 3 months so I can get it done in Jan. 2015.

[nbw1220 58]

Some issues with aetna right now. I called them today since is been a week since my info was submitted. I think my doctors office screwed something up when they checked benefits in august. They said it will be at least another 15 days. I'm really upset is taking so long

[NeNe1284 26]

I have Aetna also. 10/10 was my last appointment of the 90 day program my ins covered. They submitted my paperwork the same day n now I'm on pins n needles waiting on an approval

[dede0314 356]

@@NeNe1284 Good luck with your approval keep us updated.

@@nbw1220 I hope everything works out for you. Keep us updated.