Aetna - 3mth vs 6 mth

starbuck · April 24, 2007

Has anyone been approved from Aetna using the 3-month pre-op plan?

The surgery is covered under my plan, but the paperwork says I have to do either the 6 month supervised diet or the 3 month pre-op plan. My Dr. (Morton, Nashville TN) wants to do the 3 month, but I’m worried I will do it, then Aetna will turn around and say I have to do the 6 month.

Any advice?

faithmd · April 24, 2007

Here's some links to a couple of threads that discuss this Aetna issue, I hope they help you out:

http://www.lapbandtalk.com/showthread.php?t=31786

http://www.lapbandtalk.com/showthread.php?t=27728

If you are not yet a member of the Yahoo! Groups bandstersinsurance I suggest you go and join, there is a lot of insurance information there, it is a Group dedicated to insurance issues.

katschai · April 24, 2007

Hi - if you have not read it, below is the link to the Aetna Policy Bulletin on obesity surgery.

http://www.aetna.com/cpb/medical/data/100_199/0157.html

It is the corporate Aetna policy bulletin and not unique to any plan. I guess you already had the surgeon's office call with the diagnosis and procedures codes to make sure you are covered. So here is my two cents. See policy statement for details-The 3 month is a multidisciplinary regimen and you have to diet, exercise (duh) see a nutritionist AND be in a behavior modification program by a qualified professional.

The 6 month is doctor supervised and you have to diet, exercise and be "supervised" so you will need to have a lot of doctor visits to document in med record. So you need to decide which is going to be more time and $$ intensive for you.

I did the 6 month. I had a print out from my workout place of everytime I was there since they scan my membership card and I gave it to my doc and it was then part of my medical record. I had food logs. She kept track of my weight. My doc was supportive and submitted required paperwork. I was approved in 48 hrs.

It's not because I did the 6 month but it is because I had everything they could ever want and more.

So which ever way you go just make sure everything is documented and in medical records. GOOD LUCK

starbuck · April 25, 2007

Thank you to both!

starbuck · April 25, 2007

Question for Katschai -

Did you do your 6 months supervised by your PCP, or by your surgeon?

katschai · April 29, 2007

Hi Starbuck - i was supervised by my PCP. Good luck

steinquilts · April 29, 2007

I have Aetna and did the 3 month work up for my surgery. Alot of testing and record keeping in a very short period of time. I had to do a sleep study, hemotology, pulmonary, cardiology, diet, exercise, nutritionist, behavior testing, psych work up etc. At times it felt like a whirlwind. Everything was documented but worth it. Once all my information was submitted it took less than a week for Aetna to approve it.

celticgirl · August 24, 2008

Hi,

I read your comments and I was hoping you could give me some feedback.

I've been searching websites to see if anyone has Aetna POS II and got approved for a lapband with a doctor's letter. I'm in the middle of doing the 3 mo supervised diet, etc. I go to the YMCA to exercise which keeps a log, but my BMI is 38.5. I don't have any co-morbidities that are earth shattering other than extremely high cholesterol and triglycerides. My joints hurt when I exercise, but I persist! My hips and knees always let me know I've overdone it. I haven't been tested for sleep apnea, but I don't think I have that either. I am pre-diabetic with a strong history of it in my family. I've been severely obese for at least 5 years. I feel like I'm doing all this only to be turned down.

What were your qualifications?

steinquilts · August 24, 2008

Celticgirl,

Everyone is different to a degree. It depends on your personal history.

My history was morbid obesity for most of my adult life. I have a family history of it on my father's side. I was prediabetic, I had a pulmomary embellism and was put on coumidan. I had acid reflux for almost 20 years, high blood pressure, etc.

My ability to lose weight went to a very slow crawl and finally when I did my last diet with Nutrisystem I actually gained weight after the first month. My body was rebelling.

My qualifications was to be at the minimum of 100 pounds overweight along with everthing I just mentioned.

The testing was fast and furious and I was afraid I would be turned down. But I did everything they asked me to do in record time. I was motivated and it showed. I think that showed when Aetna approved me so quickly.

It sounds like you are doing what you need to do. Don't despare. You will make the insurance approval. Have faith. When the doctors ask you to do testing jump on it and make the first available appointment. It all helps.

Let me know what happens.

Hi,
I read your comments and I was hoping you could give me some feedback.

I've been searching websites to see if anyone has Aetna POS II and got approved for a lapband with a doctor's letter. I'm in the middle of doing the 3 mo supervised diet, etc. I go to the YMCA to exercise which keeps a log, but my BMI is 38.5. I don't have any co-morbidities that are earth shattering other than extremely high cholesterol and triglycerides. My joints hurt when I exercise, but I persist! My hips and knees always let me know I've overdone it. I haven't been tested for sleep apnea, but I don't think I have that either. I am pre-diabetic with a strong history of it in my family. I've been severely obese for at least 5 years. I feel like I'm doing all this only to be turned down.

What were your qualifications?

celticgirl · August 24, 2008

Thank you for your motivational response! I am crossing my fingers and hoping that a letter from my doctor with a detailed medical history will help. I told my doctor that I want to be healthy and I do not want to put a bandaid on my health issues, such as constant meds to keep cholesterol under control. What next? Those meds cost money and they can damage your liver. If I can lose the weight, my quality of life will improve too. I only get to go around once!

I'll keep you updated. I really hope my doctor can help get me approved. From what I read, Aetna is a bear to deal with.

steinquilts · August 24, 2008

Celticgirl,

I heard the same thing about Aetna. The only thing I can say is try not to worry before it's time. It's a waste of good energy.

I will keep my fingers crossed for you. I promise I will check back with you if I don't hear anything.

:thumbup:Take care and stay positive.

gabi311b · August 25, 2008

I am getting ready to switch my insurance to Aetna due to my job eliminating the policy that I currently have. I have a BMI of almost 38 and I am 245lbs. I have never been 'diagnosed' per se (with perscriptions) for high blood pressure, prediabetes or acid reflux but the past 5-6 times I have gone to the dr. they have told me that i need to lose weight cause my blood pressure is too high and my sugars are too high. At what point are you considered to have co-morbidities and they will look at those? I have tried everything in the book to lose weight and it just doesn't work. I have done food journals, personal trainers, NutriSystem, Weight Watchers, dr. supervised pill diets, etc. I am meeting with my dr. this friday but it's still going to be under my current insurance until January 1. I would like to get going on the pre-op stuff ASAP but I am so afraid to get excited about this if I am just going to be shot down by the insurance. Does anyone have any suggestions?