This is SO Confusing! Aetna in Virginia

[WDW Luver 0]

I am driving myself nuts trying to figure out if I am going to qualify. I called my insurance company (Aetna) and was told yes, my policy does cover banding, but the only other thing she would tell me is to read the Clinical Policy on the website--she wouldn't answer any questions:glare:. My drs office says "turn in all your paperwork and we will let you know". Well getting it all together is a pain just to have one simple question lead to a no. And I have to gain 5 pounds to meet a 40 BMI which I am working on! I will be pissed if I gained 5 more pounds and then am turned down.

Here is the confusion:

The Aetna Clinical Policy says: (bolding mine)

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 or
         
      4. Medically refractory hypertension
         

      So I have not met the criteria for the last 2 years. BMI will only reach 40 by next week (hopefully), and I have none of the listed medical conditions.

      BUT! And this is the big but. I read that in VA the Insurance codes require that the criteria to qualify only have to meet the NIH guidelines. So I searched out that State Code: (again, bolding mine)

      § 38.2-3418.13. Coverage for the treatment of morbid obesity.

      B. . . . Standards and criteria, including those related to diet, used by insurers to approve or restrict access to surgery for morbid obesity shall be based upon current clinical guidelines recognized by the National Institutes of Health.

      And I have found and read the entire 94 page PDF from the NIH "The Practical Guide Identification, Evaluation and Treatment of Overweight and Obesity in Adults" which is the clinical guidelines for doctors. No where in there is there a stipulation that the qualifying condition has to have been present for 2 years prior to surgery. Just that the BMI needs to be 40 or greater.

      So all I want to know is do I have to have met the 40 BMI criteria for the last 2 years or not? Is this a State Code that supercedes the insurance requirement?

      All of this is so confusing. Anyone understand this?

   
   

[kathyv 0]

If your insurance is through your employer, it is possible that the state code will not apply. It depends on the type of funding your plan has. Take the CPB to your physician and have them review and contact Aetna.

[crystal525 26]

Make sure your height is correct. I thought my bmi was going to be too low or borderline at 5'5". Turns out I'm 5'4" and my bmi was 41. Aetna will approve

Pretty quickly if u meet their conditions. Approval took a week once paperwork was submitted.