adagray

Not the same situation, but my PCP offered to write a letter of medical necessity if I wanted a breast reduction. So, I think I would start w/my PCP and go from there.

Mine did not charge me, but I can see why some would cause it probably takes them as long as a regular appointment to write it.

If you have weights that are higher previous to 2 years, I'd submit those w/an explanation that the lower weight within the 2 years was temporary from dieting, but you could not keep it off. At least this is what my surgeon's office is going to do for me when they submit my paperwork. I can show weights high enough for the past 5 years, but in 2007 I had some success on WW and have a lower BMI. I know they will reject my first application. That's pretty much guaranteed. But, I think we may be able to get it on appeal.

Congrats to Laurie!!! Jodi, I understand your frustration w/the 3-month requirements. I read them to mean that you go to a nutritionist, exercise therapist, and behavioral therapist every month, but I don't know if I'm interpreting it right either. In the end, I decided to just do the full 6 months. In my case, I felt like I could use the extra time to get my head wrapped around this big change anyway. And, instead of going to my PCP, I'm seeing a doctor at my surgeon's office for the 6 months (and she is also a nutritionist). She's also been really good at helping me w/the psychological aspects of this all. So, I feel like the 6 months is worth it to me. So much of this is getting your head in the right place so I don't mind waiting a little longer. And, 3 appointments every month would be hard for me since I have two little kids.

I would recommend having a sleep study done to see if you have sleep apnea. Do a search online to see the symptoms of sleep apnea. Even if you just have one or two symptoms, ask your doctor to send you for a sleep study. If you are diagnosed w/sleep apnea, then you will have the comorbidity that you need for insurance. I am in a similar situation in that my BMI is 38 (not quite 40). I have high BP too and am on meds for it so I already had the comorbidity that I needed. But, I went for a sleep study anyway (because I have some symptoms) and turns out I have sleep apnea too. I hear it is really pretty common.

I know how you feel about the diet rqmt. I had been on Weight Watchers for 2.5 years already, but that didn't count since it wasn't doctor supervised. I thought the 6 month diet would be a waste of my time, but it actually has turned out to be quite worthwhile. I decided to do the 6 month weightloss through my bariatric surgeons office. The doctor/nutritionist knew that I could not lose much weight or my BMI would go to low so we worked on other habits rather than a strict diet. First, was to just do 10 min of exercise every day for a month, the next month my goal was to make sure I was getting at least 15-20 grams of lean protein at every meal, this month I am working on decluttering/cleaning out my pantry and closet/wardrobe and reading 'does this clutter make my butt look fat' and carnie wilson's book 'still hungry'. I haven't lost any weight on the diet, but I feel like these things are helping me prepare for the changes to come w/surgery. I'm actually glad I'm doing the 6 month diet now and am thinking I really need therapy after the surgery to make the most of this. The psychologist didn't say I need it, but I can see now how much of this is psychological.

Two things I recommend... 1) Meet w/your PCP and explain that you want WLS and explain what is needed for comorbidities. Ask who she/he recommends for bariatric surgery. And, ask for a letter of medical necessity. If your PCP is supportive, then they can be a great help to make your case for you and document things in your favor to get the surgery. If your PCP is not supportive, its better to find out right away so you can move on to one that is. 2) Get a sleep study done. I was sure I didn't have sleep apnea, but the more I learned about it, the more I realized I might have it. So, I went for the sleep study and sure enough, I have it. So, now I have two comorbidities (w/my high bp). Lucky me! LOL Aetna doesn't count high cholesterol as a comorbidity. Its something your doctor should still mention in the letter of medical necessity (as extra reason why you need the surgery), but that in itself is not enough to get approved. I wish you all the best w/this. Its quite a process. I'm not done w/insurance yet myself.

This is a great thread. So great I have to post again. LOL One thing that I have found is that the more I go to my bariatric surgeon's office, the less self-conscious I feel. I am going there for my 6 month diet so that is why I'm there so often. Anyway, its impossible to know what people are thinking and not fair to assume they are thinking anything negative. Yes, I feel like I've been looked up-and-down many times, but I'm sure I'm looking others up-and-down as well... not in a bad way, but I can't help but be curious if they are just starting out, which surgery they got or are getting, and how its going for them. So, I'm giving those looker-upper-downers the benefit of the doubt now, smiling, and saying Hi. Everyone has been friendly.

I'm 5'5" and 228. I would love to weigh 150ish (which is the top end of a healthy BMI for me). I am 39 and have spent my entire adult life either gaining weight or dieting (and being hungry). I've lost 50+ twice and gained it back. I do feel like a bit of a freak at the bariatric surgeon's office because I'm on the small side for this surgery. I felt a bit self-conscience at the seminar. But, anyone who would take the time to get to know my story would understand why I need this surgery. So, I try not to worry about what people think. In fact, I'm proud to be tackling my health issues and fears now rather than waiting for things to get worse.

Seems like Aetna makes a lot of 'mistakes' as far as denying a lot of claims the first time around that really do qualify. I hear it on here all the time. I also have Aetna, but am not through insurance yet for lapband. But, I've had to deal w/them on some other things (like the billing for my second c-section) and let's just say that they don't have their act together in a lot of ways. They also outsource a lot overseas (not saying that is bad, but quality can suffer, especially in the first review of things). I found that once I escalated my billing issues, they were resolved quite quickly. Its just the first go around they got at least half of my billings wrong. And, it was a nightmare because I was going to the hospital 2x per week up until the delivery date for stress tests so there were A LOT of bills for them to mess up! Anyway, hang in there. It does take some patience, but I'm sure you'll get it worked out w/Aetna.

To put things in perspective, the risks from this surgery are far far less than the risks of being severely or morbidly obese. Personally, I don't love the idea of this surgery myself. I'm not particularly scared of surgery (have had my appendix out and two c-sections), but I wish I didn't need it. But, I do so I will. Have faith. You will come out of this great!

I think as a fat person I've learned to let these remarks trickle off of me like Water on a duck. I don't let them get under my feathers. Most people are well-intentioned, but either misinformed or lack the skills to deliver the message in a way that is not offensive. So, I always try to look at intention. Now, as a funny side-note, I remember being REALLY offended at my former PCP because when I went in to see him after losing 40 pounds on WW (and told him I had 30 more to get to my goal weight), he told he didn't know ANYONE who ever took that much off or kept it off without bariatric surgery. I felt like he was telling me my efforts were futile and it made me mad. I ranted about him to everyone I knew, but it turned out he was right. So, I just have to laugh about that a bit now. Ironically, I may have a fight w/insurance now because my BMI went below 35 during this huge effort on WW and now I've gained it all back plus 20. Ugh! Hindsite is 20/20, though. I was just soooo not ready to consider bariatric surgery at that point so he was in a lose/lose situation no matter what he said. I think this is why so many doctors just keep their mouth shut when it comes to weight even though I'm not sure if that's for the best either...

Did they tell you why you were denied? It might be something as simple as missing paperwork. That seems to be very commonl.

From what I've read on here and in my own policy, yes, if you have one or more comorbidities (as defined by your insurance company, but usually high bp, type 2 diabetes, heart disease, or sleep apnea), then your BMI only needs to be 35+ to be approved. If you have no comorbidities that you know of, then get tested. Sleep Apnea is one that a lot of people have and don't know it. I have high BP, but went for the sleep study as well since I have some symptoms of sleep apnea, and it turns out I do have this as well.

If you have picked a surgeon already, I would check w/the insurance liaison(s) at your surgeon's office. They will probably have the experience and knowledge to know how to handle this situation. Sorry I am not more help than that.

Thank you SO MUCH for your update. I'm so happy for you and happy for me too because this means I should be able to eventually get approved even if it takes many appeals. I haven't even submitted to insurance yet. I'm still getting some stuff together. Will probably submit in about one week after getting results from my sleep study back.

Well, first thing, definitely find out if you have any of the comorbidities because if you do, then you have met the qualifications and should be approved. Aetna requires a 3 or 6 month diet (details are in their clinical policy bulletin Obesity Surgery ) If you don't have any comorbidies, then I think you will probably get denied the first go-around. I'm actually in a very similar situation in that I have comorbidies and BMI of 38 right now, but my BMI went below 35 in 2006 and 2007 because I was on WW. But, I can show BMIs of 35+ for 2002-2005. I have not submitted to insurance yet (probably will in about two weeks - after my sleep study). But, I fully expect that they will deny me. Basically, from what I've read on here, the first go around w/insurance tends to be very unforgiving. If the insurance company can find ANY reason to deny you, they will. But, then there is chance for an appeal through the insurance company (where someone looks more closely as to why they are denying you and MAYBE they will approve you). Worst case, it goes to outside review which is the point at which I think both you and I would win our cases because then the approval/denial is based on NIH standards instead of Aetna standards. And, NIH says nothing about the history of obesity having to be in the last two years. In fact, that we are able to show that we could take significant weight off on our own (but without success at keeping it off) makes us ideal candidates for this surgery. Anyway, I will update here as I go along my journey w/this. And, I wish you all the best with this. I definitely think its worth pursuing. My mom got lapband just over one year ago and has lost 95 pounds. :->

I am no expert on this, but from what I've read on here before, I think you could just gain enough to get your BMI to 40 and then appeal w/the new weight. You are so close to a 40 BMI anyway, its silly they denied you. I mean you could probably 'gain' enough weight just by drinking a big bottle of water before getting on the scale or wearing some heavy jeans and a jacket. ;->

I wish you a speedy approval. BCBS seems to be one of the better ones as for approvals so I'm predicting good news from you in a few days. :->

This doesn't sound right to me that one would be covered and not the other. Did you get this documentation from your employer or the insurance company? I'm just thinking that maybe if you got it from your employer's HR dept, then maybe someone messed up and gave you outdated info (since banding used to be considered 'experimental').

Once you pick a bariatric surgeon, I think normally their office will arrange all these tests for you (at least mine did). I've only gone for two visits and I've already had most of them done (except I have one blood test and sleep apnea test left). My surgeon's office said that they've never had to refuse anyone based on the psych test and they've done thousands of surgeries (center of excellence). They do sometimes have to refer for additional counseling, but never had to refuse surgery. The written psych test is really kind of funny. One of the questions is 'Are your favorite hobbies archery and stamp collecting?'. I'm sure its in there as a guage to make sure you are actually still reading the questions (its a loooooonnnng test), but I had to laugh out loud at that one. But, the test will probably show them if you have other possible psych issues (depression, anxiety, alcoholism, eating disorder, etc.). I have generalized anxiety disorder (controlled w/medication - lexapro) and it was funny to see so many questions that I would have answered differently prior to being on meds for this. But, even if I didn't have it under control, I don't think they'd refuse surgery. I think they'd just want to make sure I got it under control before surgery.

I'm glad to have found someone who is in a similar situation as mine. Just out of curiosity, do you have documented BMIs of 35+ going back past two years? I'm going to try to submit those to help my case. I expect I'll end up being denied as you were, though, but will appeal. Worst case, I will stay this BMI for however long I need to be approved. I'm certainly not gonna diet again just to put it back on. I'm done w/yoyoing. Anyway, back to your question, I haven't submitted yet. I just didn't get all my paperwork together in time and still have some additional tests to take care of that the surgeon's office ordered last Friday. So, it may be another couple weeks before I submit. Hope that the clinical policy does not change for the worse in the meantime. Interesting thing is that when I went for the psych eval, the therapist said that a lot of the insurance companies are dropping the 6 month diet rqmt because it really should not be necessary if you have documented history of dieting already. So, who knows, maybe Aetna will loosen up their policy. A girl can hope! LOL

Aetna has this rqmt for high bp. They say it has to be 'medically refractory' which basically means that it is still high despite 'optimal medical management'. Luckily for me, I have terrible white coat hypertension (meaning mine always spikes when I go to the doctor anyway) so I have lots of high readings at the doctor's office even if it is pretty well controlled otherwise. I am going for a sleep study as well, though, just in case my high bp is not enough. The silly thing is that if someone wanted to trick the system, they could just not take their bp medicine that morning. Or, take some pseudaphed (sp?). Not that I'm suggesting these things, but for someone w/high bp to begin w/its easy to get a high reading if they need one.

Hugs! I understand where you are coming from. My situation is a little bit different. I don't have to wait because of a 'waiting period', but Aetna requires the last two years BMI to be 35+ (I have comorbidities), but I happened to lose below 35 BMI in the past two years because I was on Weight Watchers. I am still gonna submit (showing a high enough BMI up to 8 years back) and hope they will approve, but I'm getting ready emotionally for the fact that they probably won't approve it. I will appeal, but no guarantees. I just tell myself that if I have to stay this BMI for another 2 years, its not that big of a deal. Its not healthy, but at least there is a light at the end of the tunnel. I saw my mom go her whole life struggling w/obesity, high BP, high cholesterol, and type 2 diabetes and taking insulin for it. And, she just got the surgery one year ago and lost 95 pounds. Soooooo, in the whole scheme of things, if I have to wait two years longer, I can handle that. I figure if it comes to that I will just concentrate on other things during that time other than my weight. Its a relief in a way. But, yes, I would rather get the surgery now and start getting heathier earlier rather than later. Kind of ironic that I could end up penalized for making such a good last ditch effort w/WW. In my final attempt, I did it for 2.5 years and lost 45 pounds, then gained 60 pounds last year. Ugh!

Out of curiosity, I was just looking up info the 'The Apothecary Shop' since this is a compounding pharmacy close to me. Here is a link in case you are interested: Custom Compounding Pharmacy It says that they can take a pill form of medication and turn it into a liquid. Now, what that costs or if insurance pays is another question, but at least it looks like it can be done. :tongue2: