Approved by Aetna without complete Medical History

[kossde 6]

Hello everyone! I just registered here today, but I have been reading the forum for months – since I started working with my doctor to go through Lap Band surgery. Anyhow, I have Aetna Choice POS II and thought that I’d share some of my experience. I think this will be a long post, but I hope it’s helpful to those of you who are trying to get approved.

I began working with my doctor four months ago to prepare for the surgery. We did the three month pre-op routine. Over all, I went to both my primary care doctor (who also managed my diet) and the nutritionist four times – The initial visit plus one each month of the diet.

I also was advised to have a psychiatric evaluation – though according to Aetna’s website, that isn’t actually required unless you have a history of mental illness. The counselor who completed the evaluation made a note on the evaluation that he felt I would be an excellent candidate for the surgery. I don’t know if this impacted Aetna’s decision or not.

The whole process cost me less than $400 (though I think I may have to fork out another $1000 for out-of-network deduct able for the actual surgery). I paid a $20 co-pay for all of the primary care visits and the two visits for psychiatric evaluations. The nutritionist charged me $50 a visit.

During this time, I lost approximately 21 lbs (gained 3 lbs the first month and lost 24 the additional two months after my doctor threatened me with the phrase, “Aetna won’t approve this surgery if you don’t lose weight).

I followed Aetna’s requirements to a tee – excluding the aspect of having a 5 year (now 2 year) medical history. While I have had a BMI of at least 40 for at least 5 years, I went to a doctor maybe twice during that time. I was upfront with my doctor about this dilemma but she assured me that we’d figure a way to work around it. And, to make matters even MORE complicated, the two doctors I did visit LOST my records!! Both of them! So, about 3 weeks ago, I had completely given up hope of ever getting approved when I read on this site that Aetna had lowered their requirements for medical history.

Immediately I scanned in a whole bunch of pictures of me from between 2005 and now. Four of these pictures were official headshots – Passport, Drivers License, Work ID, and College ID – I did this because I knew that an official picture which had my name on it would be a lot harder to deny as ‘proof.’ Then, because I don’t generally look nearly as obese as I really am, I included about 6 full-body pictures. None of these pictures were flattering, but then again, none were inaccurate in any way either. I put the pictures in a nice little word document, placed a caption below each one stating the approximate date of the photo as well as what was going on (such as during my trip to Las Vegas or when my niece was born.) Then, I wrote Aetna a letter. This letter was about five pages long (notice how I write too much?) and detailed my weight struggle from practically day one (I was about 8 when it became a problem).

This is where it got interesting. I emailed the entire ‘letter and pictures’ over to my doctor and asked her to go ahead and send it to Aetna as is. The doctor faxed Aetna the request, but it took Aetna over a week to actually receive it and document it. I called Aetna every day for an update. On about day 4 after they actually received the fax, I was told that the request was ‘pending additional information’ – You guessed it, the nurse who reviewed my documents needed a medical history. Unfortunately, I didn’t have that! So, after going around with my doctor for several days on how to proceed- my doctor was notified by the Aetna nurse that she would have to send the information up to the people who deny or approve the requests as is since she couldn’t wait any longer. I was a little relieved; I hadn’t realized that she wasn’t the one who approved it. Well, after my Doctor called and woke me up with the ‘bad’ news, I told her to tell the nurse to go ahead and PLEASE send the request up so that someone could make a decision.

The request was approved the very same day she sent it up. I just found out yesterday. I had to call Aetna twice because I had convinced myself that the first person I had spoken to was giving me inaccurate information – that was entirely too easy, I thought. Now, I am just waiting for the letter so I can fork over the cash and get the surgery done with.

One last thing: My BMI is over 40 but I have absolutely no co-morbidities. I do have an under-active thyroid, but that only began to occur about two years ago – didn’t cause my obesity.

Sorry for the long post, but I thought it was important to let people know – YOU CAN GET APPROVED WITHOUT THE RECORDED MEDICAL HISTORY!

Good Luck everyone!

:smile:

[lonestar5212 0]

kossde - I also have Aetna POS II. I also sent photos of the last five years, they were dated digital pictures, and I also wrote a letter because I was concerned that my records from 2004 might not be found. (they eventually were and submitted) I had read on this forum back in the fall that someone else had done that, so I thought it was a great idea and couldn't hurt. I did have the 5 year history, BMI of 40, with two co-morbidites (sleep apnea & diabetes). Did the 3 month diet, did the psyc eval. even though it wasn't required, saw a nutritionist. My file was 42 pages long! And they took 4 weeks to approve me! Go figure. Like I have said before, never give up hope, you just don't know what the heck is going to happen, impossible to predict. I am so glad the requirements have changed for everyone coming after me.

[BlessedTwice 1]

Great Job! You did what any of us would have done to get approved! I'm so excited for you! Keep us posted on you surgery date!

[mstrina27 0]

Now that is great information.... my thing is my insurance is approving adipex-p for me to control my hunger and Xenical for me as well.. can't they see how long my Dr. have been prescribing that for me as well.....and take that as part of the history..

[kossde 6]

You know, I think they can take a lot of different things into consideration. My Doctor kept telling me that they were looking specifically for medical records, but when it came down to it, they approved the request with proof in the form of a letter and pictures. I almost want to think that Aetna might be utilizing more 'common sense' than the doctors offices are giving them.

The thing is, now that Aetna has dropped their requirements from 5 year history to 2 year history, worst case scenario, the person wanting the surgery waits a year and tries again. It's possible that Aetna is taking that into consideration as well when making these decisions.

:thumbup:

[bethanyjoy2824 0]

Hey since you have Aetna POS II as well I have a question.....what out of pocket expenses are you expecting? When I called they said I have a 10k maximum benefit but I can't seem to find anyone that can give me an estimate of how much more the surgery will be. Any ideas?

[kossde 6]

Hello everyone. I posted this thread well over a year ago. I wanted to just let everyone know (even tho this is in the insurance coverage area) that I have succeeded!

As of today I weigh 131 lbs. I've lost 190 lbs total since I was banded at the beginning of April, 2008. I exercise, make healthier decisions, and generally have a better quality of life. I don't regret my decision for even a moment and I also don't feel that this has been an earth shattering or incredibly difficult experience. In fact, I think that the hardest part is paying for all the clothes that I had to buy while I was dropping clothing sizes.

[HappyHomeCC 2]

Wow I didn't have to submit 2 yrs of medical, I also have Aetna Choice POS II. I did a psych eval required by the surgeon and other testing. 3 month diet. I am also just over 42 BMI to start and no comorbidities. The Aetna Nurse Liasion for my husbands company called and told me I was approved. She is a bariatric patient and was on the phone with me for 30 min giving me suggestions and pointers. told me I could call her if I ever needed to talk or support. I was somewhat impressed. I didn't expect it to be so personal , warm and fuzzy.

[CurvyCat 0]

Well, this gives me some hope.

I am barely over 40 BMI, and will be on Aetna Choice POS II starting in November.

I don't have much in the way of medical history.... I had my first physical in years about a year ago, and I was about 38 BMI then. The only other records I have are the birth certificates for my two children, which show my weights at time of delivery (278 and 254, respectively - I'm about 254 now). I did not have regular medical workups with either pregnancy - both were delivered by midwives outside of the hospital setting.

I'm hoping that whatever doctor I choose can help walk me through the process, but I think I will definitely be putting together a photo portfolio or something like described in this post.

My best girlfriend of 15 years is also looking to get banded, but she's already been through the approval process with her insurance. I would love to be able to walk this path with her as my 'band buddy', but I don't know if I'm going to be able to wrangle the approval with my insurance being brand-new (to me) and the lack of medical history. eep!!

Edited October 19, 2009 by CurvyCat

[HappyHomeCC 2]

Well, this gives me some hope.

I am barely over 40 BMI, and will be on Aetna Choice POS II starting in November.

I don't have much in the way of medical history.... I had my first physical in years about a year ago, and I was about 38 BMI then. The only other records I have are the birth certificates for my two children, which show my weights at time of delivery (278 and 254, respectively - I'm about 254 now). I did not have regular medical workups with either pregnancy - both were delivered by midwives outside of the hospital setting.

I'm hoping that whatever doctor I choose can help walk me through the process, but I think I will definitely be putting together a photo portfolio or something like described in this post.

My best girlfriend of 15 years is also looking to get banded, but she's already been through the approval process with her insurance. I would love to be able to walk this path with her as my 'band buddy', but I don't know if I'm going to be able to wrangle the approval with my insurance being brand-new (to me) and the lack of medical history. eep!!

make sure you are OVER 40 BMI so there is no question. If you are under you may have to really fight. or prove 2 other comorbidities!!!! put on ankle weights if you have too under your jeans, but make sure you are over.

[CurvyCat 0]

Maybe I should do something like that the whole way along, then. From the initial visit on --- because as of right now, if I lose more than 6 pounds during the 3/6 months diet (not sure yet which I have to do), then I'll be under 40 at the end of that.

Hopefully I'll be ok without being above 40 BMI for 2 years. I've definitely been over it for MOST of the last 6 years, and over 35 BMI for another 8 or years before that -- I just don't have the medical history as such to prove it.

But if I give myself another 5# buffer then I should be able to lose a bit during that time without going under 40 BMI.

[HappyHomeCC 2]

Maybe I should do something like that the whole way along, then. From the initial visit on --- because as of right now, if I lose more than 6 pounds during the 3/6 months diet (not sure yet which I have to do), then I'll be under 40 at the end of that.

Hopefully I'll be ok without being above 40 BMI for 2 years. I've definitely been over it for MOST of the last 6 years, and over 35 BMI for another 8 or years before that -- I just don't have the medical history as such to prove it.

But if I give myself another 5# buffer then I should be able to lose a bit during that time without going under 40 BMI.

The initial weigh in is what is submitted, once you are on the supervised diet they expect you will lose a few lbs but that is fine...