Aetna - How I Got Approved

[starbuck 0]

This is a public service announcement for those of you that have Aetna insurance. When I started this process, I looked for a specific post like this and couldn’t find one. I hope this is helpful to someone.

I have been approved from Aetna for the lap-band by completing the 3-month multidisciplinary program. This is what I did:

Month 1

Compiled 5 year weight history from various doctors (just one visit per year that documented my weight during that timeframe)

Psychiatric Evaluation

Got Support letter from PCP

Met with Bariatric Surgeon

Met with Dietician

Met with Exercise Therapist

Month 2

Attended Lap Band Support Group

Met with Dietician

Met with Exercise Therapist

Month 3

Attended Lap Band Support Group

Met with Dietician

Met with Exercise Therapist

Met with Bariatric Surgeon

Surgeon’s office turned in the paperwork and I was approved within the week!

[NanaRenan 0]

Thanks for starting the thread, Starbuck. But do realize there are other factors to consider as well.

I did everything that you did -- to the letter.

I was denied.

We provided additional info and wrote an appeal.

I was denied.

We provided even more data, wrote another appeal.

I was denied.

Once more.

I was denied.

We appealed one last time requesting that Aetna have someone who specializes in bariatric surgery look at my case.

On the final try I was approved.

Factors like BMI, co-morbidities or (in my case, the policy as our employer had agreed to it) all are huge factors in the equation. Yes, there is a process, but even that is no simple guarantee.

BUT -

CONGRATS TO YOU FOR GETTING APPROVED!!

Hooray for me for a week post op!!

And "You can do it!" to everyone else who's currently wrangling with Aetna!!!

[suziq53 0]

your a doll everyone needs to read this thanks a bunch i was wondering about all this i have done the seminar,family doc for my 3 mos diet plan iam seeing a nutritionist nx wk and have turned in all my paper work have been eval last wk ..ive met with the surg doc.and i know i need another seminar or support class before ,thanks so much for your help i have same ins co ...did you lose before your surgery ?

[jenn.ifer 0]

Hey. Thanks for the info. I have a couple questions. I jus started a new job and (in 90 days) I will have Aetna Insurance. I have been wanted to get the band for years now and havn't been able to in the past due to isurance issues, can't afford it myself. But, I am more than ready. What can I start doing now so that in 3 months when my insurance is effective, I can get this thing scheduled?? Any and all help... Thanks, Jennifer

[suziq53 0]

well i wished i had already had my 90 supervised diet with my family doc done but i didnt and thats what iam doing now ,i see him once a mo for three mos to weigh me and give me some mores to do like walk a hr a day cut back on carbs ect..but they will have you do a 90 day supervised ,and also go go go to the seminars and the group meetings and make sure you sign in at all meetings so its on recorded you attended.thats the main things you can do now that will be done in the future for u and i didnt know or i would have had it all together as well..good luck girl

[jenn.ifer 0]

Great! Thanks so much, I am going to get right on that!

[polly522 0]

And if possible, call and MAKE sure you have everything you need. Once I met with my surgeon, I called Aetna to find out exactly what I needed and what was required. I know it says something about the 3 month, but with my plan, it was six months. And my surgeons office agreed. They had said that their approva rate was much better with the six month diet program than the three. And yes, sign in at every meeting and seminar you attend!

[jenn.ifer 0]

I found this on the Aetna website..

Number: 0157

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), Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures:
   Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), 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. 
      
   2. Presence of severe obesity that has persisted for at least the last 2 years, defined as any of the following:
      
      1. Body mass index (BMI)* exceeding 40; or
         
      2. BMI* greater than 35 in conjunction with any of the following severe co-morbidities:
         
         1. Coronary heart disease; or
            
         2. Type 2 diabetes mellitus; or
            
         3. Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea); or
            
         4. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);
            

         and

         [*]Member has completed growth (18 years of age or documentation of completion of bone growth); and

         [*]Member has attempted weight loss in the past without successful long-term weight reduction; and

         [*]Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary 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:
            

            or

            [*]Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three months 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. Consultation with a dietician or nutritionist; and
               
            2. Reduced-calorie diet program supervised by dietician or nutritionist; and
               
            3. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
               
            4. Behavior modification program supervised by qualified professional; and
               
            5. Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen at each visit. (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 multidisciplinary surgical preparatory regimen.)
               

         
         
      3. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
         
      4. Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least three consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.); and
         
      5. 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. 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;
         
   
   

[jackiemhornig 0]

Fantastic Information ladies. Thank you

[gabi311b 0]

That is so awesome! I am switching my insurance this week to Aetna, from Kaiser. I am hoping to start my three month diet when the new insurance kicks in 1/1/09. I am hoping mine goes as easy as yours!!! You are helping me be more optomistic! :biggrin: