Aetna POS II Insurance Questions - Please Help!

[InIt2LoseIt 0]

My wife and I met with the surgeon in Jan 2016 to begin the journey for the sleeve procedure for both of us/together. We were feeling positive about insurance approval and now feel very concerned and are looking for thoughts/feedback from you all.

We have Aetna POS II.

My wife spoke with our primary care yesterday. He is and has been very supportive of bariatric surgery for us. However, as a result of yo-yo dieting and the timing of weigh-ins at the Dr over the years we are not at a 40 BMI for two consecutive years, but likely are above 35 BMI for two consecutive years. At our first weigh-in with the surgeon (for the 4 mos consecutive weigh-in requirement) my BMI was 45 and her’s 40.5. We have both struggled with being overweight our whole lives (trying everything and losing and gaining back etc etc.)

Her blood sugar #s do not show what Aetna considers technically/legally Diabetic, but she is told she is considered pre-diabetic. She was being treated with Metphormin for some time. She does not have high blood pressure. She previously had very high trigycleriods. She just went to her pulmonary appt but they did not schedule her for a sleep Study Test so she will call back today and advise that the surgeon wants her to have one (he does), however she is not too confident that she has sleep Apnea.

I have not been tested for my blood sugar #s in some time (years) so presently not technically/legally Diabetic. I have not taken Metphormin or the like. I do not have high blood pressure. Today I will call for my pulmonary appt and to include a Sleep Study Test. It may be likely I have Sleep Apnea.

If we weighed at Dr in 2015 sometime with a BMI of 40 or higher and then weigh in now at Dr for 2016 at BMI 40 or higher does that count as 2 consecutive years for Aetna POS II?

Thanks in advance. Desperate for this surgery for us both. My wife is 33 and looking to get pregnant the 18 mos or so after (once surgeon says it is safe for her two after surgery) – with a goal of being healthy, having a healthy pregnancy and for us to both have healthy and active lifestyles as we start a family in the upcoming years!

Edited January 28, 2016 by InIt2LoseIt

[dede0314 356]

I also have Aetna. Have you looked at their bulletin. The requirement for a two year history weight has been removed. I'm not sure if you have to follow other requirements. When I first started my journey the bulletin stated you need 2 year weight history. They have removed that statement. If you look at the revision history and on 8/12/2014 it will state what was changed.

http://www.aetna.com/cpb/medical/data/100_199/0157.html

Edited January 28, 2016 by dede0314