Atena Insurance picky

[marie_garzz_vsg 3]

My surgeon’s office mentioned that my insurance (Aetna) has started being very picky with VSG surgery approvals. The office had submitted for my surgery last week but then canceled, because they didn’t feel comfortable quite yet and want me to get a sleep apnea test done. I was at the required BMI 41 at my consult and started to lose weight right after to lose 15/20lbs required for surgery. They feel because I’ve lost weight so quickly in the past and now they may not approve, I don’t have any huge medical issues. I’ve battled with obesity my entire life and have lost and gained weight since I was in middle school. I’ve done every diet out there, but my body has started to react to diets suddenly. I suffer from severe Migraines and dieting flares them up really bad. So I chose to do a VSG. I’ve done all the required testing and didn’t do a sleep apnea test because I was at the required BMI. Now they are saying it’s best I do it. I don’t think I have any sleep apnea issues. So I don’t think I’ll fail the test. I’m so stressed and annoyed, I can’t afford self pay. Any advice is appreciated.

[kellym1220 474]

It does seem unfair, but if you do the test you might find that you are borderline sleep apnea-tic (?) and they will push it through. If not, and they don't go ahead and approve you, then I would contest it. I would never have thought I had sleep apnea, but my doctor said I did. My insurance doesn't cover WLS at all, so this was before I even considered it. Turns out...I could not sleep with a CPAP machine, so I gave it up quickly. I know I get a much better night's sleep without the 70 pounds that I have lost!

[floridagirl23 3]

I have Aetna also and was required to take the test in order to qualify since my BMI is only 36. I really didn't think I had sleep apnea either but took it and found out I have very mild sleep apnea which helped me qualify.

[marie_garzz_vsg 3]

4 hours ago, kellym1220 said:

It does seem unfair, but if you do the test you might find that you are borderline sleep apnea-tic (?) and they will push it through. If not, and they don't go ahead and approve you, then I would contest it. I would never have thought I had sleep apnea, but my doctor said I did. My insurance doesn't cover WLS at all, so this was before I even considered it. Turns out...I could not sleep with a CPAP machine, so I gave it up quickly. I know I get a much better night's sleep without the 70 pounds that I have lost!

Thank you so much! Waiting on scheduling to call me for the sleep apnea test. It will be a at home test.

[marie_garzz_vsg 3]

27 minutes ago, floridagirl23 said:

I have Aetna also and was required to take the test in order to qualify since my BMI is only 36. I really didn't think I had sleep apnea either but took it and found out I have very mild sleep apnea which helped me qualify.

Oh that’s good to know and makes me feel better.

[JaysWife 22]

I have aetna also and dear God what a NIGHTMARE! I have been going back and forth with 2 denials so far even tho I have done everything they require and then some! My provider even made the statement that they have little hope at this point of getting a favorable decision even tho my bmi is 45and has been for at least 25 years and I have ridiculously high bp. Good luck is all I can say 😞

[marie_garzz_vsg 3]

Is your insurance through your employer? I doing my sleep apnea test tonight at home just to cover my basis. I hope you will keep appealing.

[JaysWife 22]

It's through my husbands work. It's so bad even their HR department has reached out to them as well... It's a whole mess.

[marie_garzz_vsg 3]

Ugh that sucks! I sure hope mine doesn’t give me hell because I’m ready to fight them till the very end. Don’t give up, keep fighting them! I told my surgeon, that I could never afford to self pay for the surgery and that I was gonna fight them till the end. They know I’m not going to just give up. They were already sending me the self pay costs. Sending you positive vibes and don’t give up you got this!!

[JaysWife 22]

Thanks! I am sending the same for you! I hope it is smooth sailing for you!!! Good luck!!

[nursesunshine 9]

On 3/21/2021 at 9:51 AM, floridagirl23 said:

I have Aetna also and was required to take the test in order to qualify since my BMI is only 36. I really didn't think I had sleep apnea either but took it and found out I have very mild sleep apnea which helped me qualify.

I'm so glad I saw your post. I've been worried my insurance provider won't approve because I have mild sleep apnea. The comorbidities covered includes sleep apnea but doesn't say it has to be severe like my old plan.