Question about insurance approval/denial process...

[adagray 1]

So, I got all the info from Aetna (my insurance) for what it takes for precertification. And, confirmed that I don't have an exclusion. Based on the precertification rqmts, though, I expect that this will be a fight for me to get approved. So, I'm wondering if it is better to apply for precertification before the 3 or 6 month diet to see what they are gonna fight me on. Or, are you supposed to wait until you THINK you meet ALL of the rqmts to submit your first precertifcation. The thing is that I would not want to do the 3 or 6 month diet unless it is going to help me get insurance approval. If I can't get insurance approval, then there's no point in doing that diet (at least not right now).

So, here's why I expect a fight... Aetna requires that the last two years' BMI be 35+ (in my case, I have comordity of high bp which is not controlled well w/medication).

But, my weight history looks something like this...

2002 - 36

2003 - 35

2004 - ? ( but less than 35 probably because I was on a diet)

2005 - 35

2006 - ? (but less than 35 because on WW)

2007 - ? (still on WW - hungry hungry hungry!!!)

2008 - 35 (but that was at the very end of 2008)

Current - 37

So, I have a history of always returning to the 35+ range, but I always diet to try to get it back down so there are interspersed lower BMIs in my history. I expect Aetna to deny me, but that I may be able to get approved through appeal. If I can't get insurance to approve, then I don't mind staying at this BMI for however long it takes. Anyway, that's all just to give you some background. I'm really just wondering about the process of when to submit my first precertification request (before or after the 3/6 month diet). Thanks!

[tashanicole1271 0]

Ok, I have Aetna also and I was approved a week after sending in all my information. From what you are saying, Aetna will probably deny you because of your BMI not being high enough. Having said that, I would go to my PCP and see if you have any more comorbidities besides the elavated BP. If your BMI is not 40, the more comorbities you have the better. Have you gone to a seminar with a surgeon yet? I would do that to see all the things that are required to be submitted for approval, then get started. I didn't have a precertification. I went to the seminar and started marking off all the things that were required. It took about 6 months to get everything done, but I was approved with no problem and my surgery is 1/14! Good luck to you!

[adagray 1]

Ok, I have Aetna also and I was approved a week after sending in all my information. From what you are saying, Aetna will probably deny you because of your BMI not being high enough. Having said that, I would go to my PCP and see if you have any more comorbidities besides the elavated BP. If your BMI is not 40, the more comorbities you have the better. Have you gone to a seminar with a surgeon yet? I would do that to see all the things that are required to be submitted for approval, then get started. I didn't have a precertification. I went to the seminar and started marking off all the things that were required. It took about 6 months to get everything done, but I was approved with no problem and my surgery is 1/14! Good luck to you!

Thanks for your advice. I am actually seeing my PCP this coming Tuesday to talk about lapband and get her recommendation for a surgeon. But, I also made a reservation to attend a seminar w/Scottsdale Bariatric Center next Sunday already as well. Even if its not the surgeon my PCP ends up recommending, I figure it doesn't hurt to get as much info as possible. Anyway, I will definitely ask my doctor about testing for additional comorbidities. I had full bloodwork done in late November, though, and was a little surprised I don't show as pre-diabetic. I feel just awful when I eat high glycemic index type foods. But, I wonder if I don't test as pre-diabetic because I just avoid those foods now.

[daco525 0]

Do you have any complications or pains with joints. I too have a BMI of 35-38 (I fluctuate), I have high bp, diabetes, and high cholesterol. I recently developed some problems with me feet and ankles which I believe is related to weight. I am going to see about having the podiatrist send a letter on me behalf for lap band also. The more people (doctors) on your side the better. I started my 6 month doctor visits last month. I am counting on approval because of the comorbidities. I did speak with the ins. and they seemed positive. Have you tried calling them first. By the way, when I submit my paperwork I will not submit any of my weight under 35, I too have several because of various diets. My ins. only requires 2 years history.

[kfgates 0]

BC BS approved me after 2 days. My BMI is 35-38. My comobidities are many....herniated discs, stress incontinence, pre diabetic, extreme joint pain, plantar faciatis, (fallen arches) and others. I made sure I did everything they required and doted my i's and crossed my t's. I even got letters from not only my PCP, but my OBGYN, my pediditrist and a very heartfelt lettter from me. You can't send them TOO much information. I even printed my weekly diet sheets for 6 months. I am scheduled for surgery on Feb 13th (yup it is a Friday) so I am waiting for the other boot to fall...ie: oops we called the wrong patient, or oops you lost too much weight and they changed their minds. I was so sure I was going to be denied that in order to not fall into a complete depression I did loose some weight. If history repeats itself I would have gained it back without the band. Please feel free to ask questions if you have any. K