Aetna with BMI less than 40

[Puddles 23]

Has anyone had experience in dealing with Aetna with a BMI less than 40?

My present BMI is 39. I have not been diagnosed with one of the co-morbidities listed for BMI 35-39 . I have just been diagnosed with non-alcoholic fatty liver disease and have a GGT level that is greater than twice the high normal limit.

I have been overweight/obese most of my adult life. I do have documentation of pre-diabetes A1c levels in 2011, 2013 and 2014. In 2012, I had lost 50 lbs. doing a very low calorie medically supervised diet and all my lab work looked tremendously better. In 2012 my BMI placed me still overweight, but no longer obese. I have gained those 50lbs and 20 more. *sigh* I have changed my diet dramatically in the last 6 months with no change in weight.

The NAFL (non-alcoholic fatty liver), puts me at greater risk for cardiac disease, insulin resistance, metabolic syndrome, type 2 diabetes etc. One of the symptoms of a high GGT, and actually one of the reasons I went into the Dr, was fatigue. I wake up tired and spend my day fighting the fatigue. I try to get out and walk our neighborhood, but some days that is very difficult due to the fatigue.

My physician, after going over my history, has recommended bariatric surgery. There is no cure for NAFL, but studies have shown that weight loss has a dramatic effect on it as well as on the GGT level. I feel stuck in the middle of no man’s land. I don’t weigh enough to qualify for morbidly obese – need approx. 12 more lbs. for that. I don’t have one of the listed co-morbidities Aetna states I need to have, but I do have all the “pre” lab work and risks for several of the co-morbidities. To me it would seem to make sense to allow me to have the surgery before I have permanent liver damage and all the health complications that are going to be much more costly in the end.

[ab123. 90]

What about sleep apnea?

[Puddles 23]

What about sleep apnea?

Nope, no sleep apnea. Mr does, big time, but not me.

That is part of the frusterating part is I am sitting on the cusp of everything, but not there yet. Would prefer to not get there if I don't have to, but aetna does not see that as cost prohibitive I guess.

[ab123. 90]

Still have your MD submit it with his recommendation that it is medically necessary. What is listed is their guidelines. You never know.

[Puddles 23]

Still have your MD submit it with his recommendation that it is medically necessary. What is listed is their guidelines. You never know.

Thank You Lynneanne.

My physician and I are working on getting all the data together. Part of the difficulty I have at the moment is that I am living in Australia as an ex-pat, and my records are in the U.S. I have gotten part of them and working getting the rest of them sent via e-mail over. We plan to submit the request with research backing up the request, along with the data that I have of my lab work previously which demonstrates improvement with weight loss. I am just hoping they will accept the VLCD weight loss program that I did for over nine months, even though it is out of the two year period they request.

[ab123. 90]

Still have your MD submit it with his recommendation that it is medically necessary. What is listed is their guidelines. You never know.

Thank You Lynneanne.

My physician and I are working on getting all the data together. Part of the difficulty I have at the moment is that I am living in Australia as an ex-pat, and my records are in the U.S. I have gotten part of them and working getting the rest of them sent via e-mail over. We plan to submit the request with research backing up the request, along with the data that I have of my lab work previously which demonstrates improvement with weight loss. I am just hoping they will accept the VLCD weight loss program that I did for over nine months, even though it is out of the two year period they request.

Good luck. Just keep picking away at them!!