Approval questions

[2Bsmaller18 436]

I am in the beginning stages. I have a BMI of 36 so I am borderline and per Aetna insurance I need to have a comorbidity. I did a sleep study and the ENT called me and said I have "mild sleep apnea". Has anyone every been told this. Would this qualify me for surgery? He said I didn't need a CPAP, but recommends losing weight and maybe a mouth appliance. I am worried I will go thru the extra time and expense to have all of the things the insurance wants me to do and may end up looking at a cash option or not getting surgery at all until I develop diabetes or another issue down the line.

The other question I have. The surgeon (not insurance from what I understand) is having me have a psych eval. I don't have a history of depression, take any psyche meds etc. Are they looking just to see if I am doing the surgery for the right reasons and motivated to make long term changes? Is there a reason I wouldn't pass the eval?

[Matt Z 4,140]

8 hours ago, 2Bsmaller18 said:

I am in the beginning stages. I have a BMI of 36 so I am borderline and per Aetna insurance I need to have a comorbidity. I did a sleep study and the ENT called me and said I have "mild sleep apnea". Has anyone every been told this. Would this qualify me for surgery? He said I didn't need a CPAP, but recommends losing weight and maybe a mouth appliance. I am worried I will go thru the extra time and expense to have all of the things the insurance wants me to do and may end up looking at a cash option or not getting surgery at all until I develop diabetes or another issue down the line.

The other question I have. The surgeon (not insurance from what I understand) is having me have a psych eval. I don't have a history of depression, take any psyche meds etc. Are they looking just to see if I am doing the surgery for the right reasons and motivated to make long term changes? Is there a reason I wouldn't pass the eval?

It's going to be case by case, but if the approval request is worded correctly, listing "sleep apnea" and not "mild sleep apnea" as well as leaving off the "no cpap required" they might be able to slide it through. Don't forget you can appeal if they do deny. Seems most appeals get approved.

The eval isn't just for issues you may or may not have at the current moment, but to assess if you are able to mentally handle the stress that will happen during your post op recovery. I was quite ready as this is my second go round with WLS and it was still very mentally stressing with all the changes. Reasons you wouldn't pass range greatly, that would be a very good question to ask the psy, maybe *after* the eval.

[mousecat88 2,281]

11 hours ago, 2Bsmaller18 said:

I am in the beginning stages. I have a BMI of 36 so I am borderline and per Aetna insurance I need to have a comorbidity. I did a sleep study and the ENT called me and said I have "mild sleep apnea". Has anyone every been told this. Would this qualify me for surgery? He said I didn't need a CPAP, but recommends losing weight and maybe a mouth appliance. I am worried I will go thru the extra time and expense to have all of the things the insurance wants me to do and may end up looking at a cash option or not getting surgery at all until I develop diabetes or another issue down the line.

The other question I have. The surgeon (not insurance from what I understand) is having me have a psych eval. I don't have a history of depression, take any psyche meds etc. Are they looking just to see if I am doing the surgery for the right reasons and motivated to make long term changes? Is there a reason I wouldn't pass the eval?

Like Matt said re: the sleep apnea, it's really an insurance case-by-case basis. I have very mild sleep apnea that does not require a CPAP, but it's still a diagnosis of sleep apnea, so that counts as a comorbidity since it would be relieved with weight loss. Your surgeon should be able to tell you if that works for Aetna. And Aetna should also be able to tell you.