Aetna Insurance Experiences

[Lady Lap Band 71]

I called Aetna and they said they cover 90% if the Lap Band so long as you meet the following criteria:

Selection criteria:

1. Presence of severe obesity that has persisted for at least the last 2 years, defined as any of the following:
   
   1. 
      
   2. Body mass index (BMI)* exceeding 40; or
      
   3. 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 at each visit. This physician-supervised nutrition and exercise program must meet all of the following criteria:
         

         I am curious to see who has been approved by Aetna. If you have or have not, what is your height, weight, and bmi?

         THANK YOU!

      
      
   4. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
      
   5. 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
      
   6. 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
      

[sunyinfla 0]

Personally, I think its pretty great that Aetna posts their policy details on their website. It lets you see exactly what information they require in order to establish the necessity of the surgery. Better yet, and what most dont seem to understand, is that these "requirements" are developed by standards used within the medical community. Aetna didnt just pull this information out of a hat.....the basis is what various medical societies suggest their surgeons follow, its the standard in teaching hospitals etc. Personally, if your doctor isnt already standardly following some of these steps, you might want to rethink your surgeon. The steps are all being asked so that you have a better chance of a good outcome with your surgery and that you are set up for success before the first cut.

That being said, you increase your chances of an approval when you make certain the necessary medical records are submitted. Its not just letters from your doctors saying you need the surgery, its copies of your chart notes showing you were followed medically for the weight loss attempts, etc.

:cool: Best wishes!

[SassyOne 0]

Hi,

I also have Aetna and was banded on Oct 13,2008. When I originally questioned Aetna 18 months ago, I was told that my plan did not cover any type of gastric surgery. Luckily their rules regarding gastric surgery have changed this year and it is now covered. I had to follow their rules (my surgeon's office staff were great with this) and Aetna has paid out according to my deductible, co-payments and using in-network doctors. My surgeon apparently has some kind of agreement with Aetna for a condensed 3 month supervised period prior to authorization. Once I completed my 3 months of supervised visits, nutritional counseling, the pysch consult and getting all appropriate letters from my assorted doctors I received my approval within 1 week of submission and had my surgery 2 weeks later.

I suffer from high blood pressure (though I am down to only 1 med from 2), have severe arthritsis in my knees (also down 1 med from 2) and had a BMI of 53.

My only suggestion is to question them specifically as to what your plan covers (if you haven't done so yet). I called them at least 3 times over a few weeks to make sure that I always got the same answer regarding my coverage and financial responsiblities (wanted to make sure that it really was correct).

Good luck .... It really was worth all the hassle ...

[sunyinfla 0]

Another thing to remember is to check out with your insurance to see if your group employer plan excludes weight loss treatment and/or bariatric surgery. Its not the insurance company that excludes these.....its your employer not opting to include coverage for the services.

[rhonaker 0]

I have been approved by Aetna, It took about a month. I am 5ft. 3 and weigh 219 pounds which worked out to exactly 40 bmi. I have a couple of co mobidities, but nothing serious. I believe they are pretty good about allowing if you are between 35 and 39 BMI and have diabetes or other comorbiditis. I worked with a terrific group here in bakersfield that did all of the applications for insurance and have a wonderful support group. I am scheduled for surgery Nov. 24th and can't wait!

Hope the info helps.

[changing 2]

I have aetna also but unfortunately my employer has excluded it.so not i am trying to figure out what to do.to be self pay bwould be about 17500.00.right now i do not have 2000 towards that.but i congratulate everyone who has been approved or is able to be self pay.