Question - medical necessity?

[Guest Annalise]

Hello everyone! This is my first posting. I am right in the middle of gathering information about this whole process. I talked with my insurance carrier (Aetna) and bariatric surgery for weight loss is a covered benefit for my particular policy with no cap or limit on the procedure so long it is medically necessary. Please correct me if I'm wrong but from everything I've read a BMI of 40 or more qualifies you for the surgery and is what's considered medically necessary IF this type of surgery is a covered benefit on your policy. The Aetna representative told me this surgery (CPT code 43843) is like any other surgery on my policy - all I need is a referral from my PCP and there has to be a medical necessity. Does anyone have any input on this? I know it is a covered benefit of mine, but now I am wondering about the "medical necessity" part. Thanks everyone!!!!

[nightingale2u 42]

Usually having a BMI that is 40 or higher qualifies the procedure as medically necessary... you can have a lower BMI if you have other co-morbidities such as high blood pressure... high cholesterol... diabetes... arthritis... etc. Hope that helps

[Alexandra 55]

Hi Annalise,

Darcy is right. Medical necessity is determined by your specific medical situation, but broadly painted the standard is that if your BMI is 40 or more that all by itself is enough to make bariatric surgery medically necessary. I know Aetna feels that way. If your BMI is lower than 40 you'll need two "co-morbidities" to make the surgery medically necessary. If you fit either of these descriptions, your surgeon's determination is all your carrier will need to agree that surgical treatment is medically necessary.

However, I'd caution you to talk with your doctor about whether he's had success getting Aetna to cover the band. Bariatric surgery may be medically necessary, but laparoscopic adjustable gastric banding is still considered by Aetna to be too new to be a standard surgery. They might be very happy to approve you for RNY but deny your request for banding. So don't count your chickens until your doctor's request for precertification is approved.

Good luck! And PLEASE come back and let us know how it turns out!!

[Guest Annalise]

Thanks so much for the advice. I will make a call back to Aetna and specify exactly which bariatric surgery I am interested in. Thanks again!

[the best me 6]

Hey!, you gave them the right code for the Lap Band surgery...43843...things are looking very hopeful, but listen to the advice posted here, and let us know how it goes!! Good Luck!

[Gigi001 0]

Guess What? I am due for surgery on March 1 and when the hospital called for precert (otherwise I'm handing them a check of course) they got the word that band IS covered at 80% after deductible up to $xx and then 100% after that -(i.e, the way anything is covered in my plan).

So I didn't really believe this, and I called myself, got someone else on the phone who after a pause said YES it is covered procedure, yadda yadda same details. It is funny coz my surgeon wrote this long, beautiful note to the Medical Reveiw Bd at Aetna but we might not need it. But that was independent confirmation with 2 reps. YIPEE.

So I should know for sure this week whether I, in particular, am getting it covered.

[Guest Annalise]

That is so awesome!!! I sure hope it all works out for you in the end (as far as insurance goes). Thanks so much for your reply. Best wishes!

[GeezerSue 7]

from Aetna.com...

Vertical Banded Gastroplasty (VBG) and Laparoscopic Adjustable Silicone Gastric Banding (LASGB or Lap-Band):

Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) or laparoscopic adjustable silicone gastric banding (LASGB, Lap-Band) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following comorbid medical conditions:

1. Hepatic cirrhosis with elevated liver function tests; or

2. Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or

3. Radiation enteritis; or

4. Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or

5. Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV) (see Appendix).

This is as of December 2004. If these conditions are NOT met, Aetna does not routinely cover the procedure. Go to www.aetna.com, then click on doctors on the left, then Medical Policy Bulletins, the look up Obesity surgery. Good luck.