My head may explode....Atena insurance is trying to kill me...

Michelle Tarver · August 7, 2015

So, I met with the Surgeon last Friday, she suggested to double check with the insurance company about coverages,co-pays,ect. And the Surgeon told me NOT to lose any more weight. That I would go below 40 BMI and not qualify for the surgery.

So Wednesday I called them. gave them the procedure code. Was told yes we cover the surgery.There are some conditions you need to meet. here let me send you the Clinical Policy Bulletin to read.

So I read it. It does say the BMI has to be 40,but it also says you must do EITHER a 90 day multidisciplinary approach ( NUT, Behavioral,exercise ) OR a 6 month weight loss plan BOTH be mainly face to face. I am doing the 90 day one. However I can not have the Surgery until late Jan/early Feb.

So I asked about the BMI..at what point do they look at it ? On surgery day? At the start of the program?

Was told to re read the policy builtin and ask my doctor. They should know. So I called the doctor. They were like well we don;t know until we put in for pre authorization what your insurance really requires. We have a general idea. But if you want policy specifics call the insurance company.

So I call BACK the insurance company. I am again told to read the policy bulletin. I said I have it DOES say 40 BMI..BUT NOT when, The woman on the phone says" we can't answer clinical questions you have to ask your Doctor.."( ok getting frustrated here!) "But IN MY experience They looked for the past 2 years of BMI above 40 before they would approve me for a LAP band" but that was all she cold tell me.

So I called the insurance company BACK AGAIN. I ask.. I read the Policy Bulletin, I know the BMI has to be 40, but at what point and for how long?

I get told.. read the bulletin I said I have It does say 40 BMI but not anything about time period or length of time prior to surgery.

Can you please answer this question? Ins co: We do not answer clinical question." me: This is not clinical it is about MY policy. NO it is clinical. The policy Bulletin says nothing about the time period to be at 40 BMI. Ins co says: It is not for you to read it is for your doctor,

I reply : You sent it to me. They reply it is for your Doctor. I reply.. it is in English? INs Co says yes. I reply that I am educated enough to read English. She again says its for my Doctor. I asked her, Do you think I am unable to read English? The information I am looking for is not in the bulletin. So if these are the guidelines and it is not in the guidelines then they do not apply to my policy I asked? Ins Co says: That is not the case. So I said... Where do I find these guidelines? Ins co says ask your doctor it is a clinical question, I said it is a POLICY question I am not asking you how to do the surgery or WHY to do the surgery. I am asking what my policy says about the surgery. Ins co : it is in the clinical policy bulletin. I reply I read it it did not answer my question. Ins co says it is not for you it is for your Doctor. gain I say I can read English.

I now ask for a supervisor. Of course the supervisor is "not available, I can leave a voice mail and they will get back to me in 24-48 business hours." UM its 12 on Friday..So that is like Tues ..Not acceptable... Wee go round and round... I ask for a different Representative.

I get a different Representative. I tell her I am investigating getting a vertical sleeve. I understand my BMI has to be 40, But the day I start the program or on Surgery day? And I now hear Atena will be looming for a BMI of 40 or more for 2 years prior to surgery...Is that correct?

Again I am told this is a Clinical question and they can not answer. I reply that it is a POLICY question. She says I can send the policy bulletin I say I have read it and it does not answer these 2 questions. Again I ask..So if it is not in the bulletin it is not required by my plan? She said not necessarily. I explain to her I have gone back and forth with the Dr's office.and the Ins company on this. That it really seems to be a Policy issue to me as my Dr says it is. I am trying to save Atena MONEY on tests and appointments for a procedure I now may not qualify to get until Nov 2016. But we won;t know that until I have all these appointments and tests and apply for pre approval in Nov 2015.

So she says we can have the doctor do a pre determination..kinda like a mortgage pre approval but not funding the loan get it?

So I had to call the doctors office back and ask them to put in for the pre determination. UGH my head hurts.

Looking at my medical record on line IF they do want 2 years of a BMI at 40 I have to wait until Nov 2016.....I would rather know that now before I do the Endoscopy and upper GI testing I don't wanna get my heart set on having it done THIS November and THEN find out I have to wait ..(of course Dear Hubby says to just keep loosing it myself : :huh: ...if I have to wait at 40 BMI till Nov 2016..)

Soo yeah that is my day.. How is yours?!

ShrinkingPeach · August 7, 2015

I have Aetna and I had to show all my PCP notes showing weight loss attempts from the past 2 years with no weight gain. 3 months of those had to be consecutive.

I had to have a letter from my PCP recommending the surgery and listing my BMI and co-morbidities.

I was at a starting BMI much higher than you, so I can't say for sure how it will work for you. Aetna does have a few requirements but they are not as tough as some. I have even heard that if the BMI is lower but you have co-morbidities they will take those along with the weight into consideration.

Good luck and try not to kill anyone in the process...one day you will look back on this and hopefully laugh?

Michelle Tarver · August 7, 2015

Oh I hope I will laugh. I don't have any co morbidity issues yet...at this rate the "pre diabetes" becoming diabetes might in a sick way be a good thing! If I had co-morbitities I could have a BMI of 35. I was 280 in May when I started I can't recall what BMI that is. I am 268 right now. I can go no lower than 263. I am 5'7".

My Dr office said Atena is one of the tougher ones to work with.