Aetna....Super Discouraged now

[sammyxann 0]

Does anyone know what aetna's policy on lap band is? I went on their website and got some information but then when I ran a search it said that Aetna is now requiring a complete medical history, you must have had a BMI of over 35 for at least 2 years (2 years ago mine was 33.3) must have a medically supervised diet for 2 years. Anyway, does anyone know what the current requirements are? My hubby just passed 90 days at a new job and our insurace will be effective Jun 1st so i can't call and find out yet.

I am currently on Kaiser Cobra and wondering if I shoud just stick with that and try to get them to cover it.

Any info/suggestions would be greatly appreciated.

[txaberry 0]

I have aetna and I was approved in January and banded in March 2008. They cover it, but you first need to make sure that your husband's company doesn't exclude it. Some companies make an exclusion to bariatric surgery. If you call they were really good about explaining it and checking if your company approves.

[whaletail 0]

I have Aetna HMO. They required a 3 month pre diet and letter from my primary doctor, and my surgery was covered 100%. I had a $100 copay. It mostly depends on your place of employment, which tells the insurance company what they want covered. When all my paperwork was submitted, I was approved in 6 days. It was a really smooth process. I would call Aetna and ask them about it, they are really friendly and helpful. I have never had a problem with Aetna, I've been with them for over 10 years. Good Luck!!!!

[Neeley 0]

I see that some of the answers you have got does not give you all of the information so here it goes. Aetna requires a 5 year weight history ( mine read as follows by year 245, 230, 170 190 and 215) you do not have to have two years it's 5 and there can be a dip and peak in the weight it shows you can not keep it off. You will also need a 6 month medically supervised diet now my doc did that for me in 3 months, you will need need a bmi of 35 or over and co-morbid conditions.

[Flowerpurr 0]

Aetna no longer required a 5 year weight history it's only two. They changed their policy. Here is a copy of it.

<TABLE cellSpacing=0 cellPadding=0 width="100%" border=0><TBODY><TR><TD id=spacer width=16 rowSpan=3> </TD><TD class=contentbucket vAlign=top width="100%" rowSpan=2> Clinical Policy Bulletin:

Obesity Surgery

<SCRIPT src="http://www.aetna.com/assets/script/search_keyword.js" type=text/javascript></SCRIPT>

<NOSCRIPT> <!-- browsers or browser setting that can't read js will have this feature disabled --> </NOSCRIPT>

Number: 0157

<TABLE cellSpacing=0 cellPadding=0 border=0><TBODY><TR><TD>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 or Lap-Band) 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. 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. (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.)
               

            </TD></TR></TBODY></TABLE>

            </TD></TR></TBODY></TABLE>

         
         
      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;
         
   
   

[aubrie 6]

I required a 6 month history. It was the pits. They required all kinds of stuff for me. I spent hundreds on all kinds of nutritionists, sleep studies, heart exams, yadda, yadda, yadda. Then the bastards denied me. I cried for 3 weeks, then got mad as hell and fought them tooth and nail. I was finally approved after ELEVEN MONTHS. So don't give up. APPEAL!!!! Have every doctor you know write a letter on your behalf. I did and it seemed to do the trick.