Aetna- insurance requirements

[amy36 0]

:scared2: This is my first post. I have Aetna insurance and have been told by Aetna that my type of insurance does cover lap band surgery. I have gone to the initial lap band seminar. I have had the pysch eval, the nutritionist consult, and an appt with the nurse practitioner on staff. My hospital here in NH has never dealt with Aetna for this procedure so the insurance liason is not very clear what the expectations are for Aetna. We are reading the clinical policy bullitan very carefully, and yet some of it is unclear. There are clearly 2 options; 6 month and 3 month. I would love to do the 3 month option but am unclear about the exercise regime part. It says you must work with a certified exercise therapist or "other qualified professional".

I would love to hear from people who have done the 3 month option and been approved. Could you tell me exactly what you did to meet this requirement in particular.

Any help, much appreciated!

Amy

[BigMomma 0]

On one of the other threads someone stated that the dr just made a note that the person was exercising on each visit. My center recommended scans from the gym or receipts of membership payments. (I am going to try for the documentation on each office visit.)

[Julia_N 2]

I have Aetna and just had surgery. I guess it differs by policy. I had to do a 6-month diet, but no formal exercising. Every month my doctor asked if I was exercising and I would say I was doing 15 minutes of walking. Approval went though on the first try. Good luck!

[horizontravel 0]

aetna ppo approved me 8/5/09. They were good and fast. They will do the same for you. I will be banded 8/12/09:thumbup:

[WDW Luver 0]

The 3 month program is new and not many have been approved under it yet. I am the first one at the WLC here that is doing it. I am currently waiting for my approval and it is taking them quite awhile. I am really hopeful that it will come this week.

The exercise part of it is the most misunderstood part of the 3 month because no one really knows what the requirement wants--including Aetna!! My dr documented in his records what I did. But I also have a contraindication to exercise and he noted that I was trying but not really able to.

If you want to be overly cautious you can hire a personal trainer and then document each visit with them and have them sign something for you. If you go to a gym you can see if you can get a printout of your visits. If you exercise independently--like walking-- then make sure your doctor notes it each visit.

Just to be safe, while I am waiting for approval under the 3 month plan I am continuing my visits with my PCP and the nutritionist so if they deny based on the exercise part I can resubmit in 3 more months under the 6 month.

Don't wish we could lose weight with all this jumping through hoops?!!

[vagabond 0]

I visited my PCP the first time and then 3 times following. On my first visit he set me up with visits with the nutritionist for three visits. The nutritionist and the PCP both noted that I was following a diet and exercise plan. After the 4th PCP visit my Dr. sent the inforamtion to the surgeon who then forwarded it to Aetna. I was approved in 3 days. The big question for me was what if I didn't lose any weight (I did not lose any weight) if I would still get approved, I did. I had high blood pressure, diabetes and BMI of 42 so I obviously needed the surgery.

Good luck, it was not as hard to get approved as I though it would be!

[tdevinrn 0]

To "horizontravel",how did you get such a fast surgery date so soon after your approval letter? how did you get past the 3 month documentation of dieting and all the other stuff?

[Jodi73 11]

I was just approved under the three month plan. My PCP documented at each of the 4 visits what type and how much exercise I was doing. IMHO I think a doc is a "qualified professional" I was approved in just over a week after submitting.

I did one official visit with a nutritionist, but also two classes (required by my doc) that the nutritionist was present/taught at.

Hope this helps!

Good luck! Jodi

[voodoo 0]

I have aetna and I had something very uncool happen.

The insurance coordinator called aetna to ask

if I was covered.

She called me back to tell me how sorry she was,

but there was an exclusion on my policy.

I sat at my desk and was completely deflated.

Then I thought, "no...this feels wrong. Not taking 'no' for an answer."

So I called aetna, talked to a very nice woman...

told her what happened. She pulled up my stuff and said,

"Um, no...there is an exception in here."

And that's when she listed the comorbidities.

She made a conference call to the insurance coordinator to tell her.

Come to find out, the girl that spoke to the insurance coordinator, didn't look into my file,

she just regurgitated the most common answer to the WLS question.

She was reported to her supervisor...for almost changing the course of my life!

What if I had just cried myself to sleep and hadn't fought harder?

My first consult is Tuesday.

Can't wait.

[WhyW8 0]

My initial problem w/Aetna was when I called to ask about nutritionist visits. One person told me it was NOT required so don't do it.

When I reread my book it said it IS required. I called back and was told it IS required but Aetna does NOT pay for a nutritionist visit so it was up to me if I wanted to see one.

Why would I not want to see one if not seeing one meant I would not be able to qualify for surgery????

Glad I figured that out before going thru 3 mo. of other multi. visits & have surgery denied b/cause of Aetna employee giving me the wrong info.