Well my surgeons office just called me they are submitting my paper work tomorrow for approval. Boy am I getting nervous. Maybe I shouldn't read so much on here and other forums. Keeping my fingers crossed. :rolleyes

You guys make me both hopeful and fearful! I have Aetna POS (PPO) and will be submitting next week for initial pre-cert...so if the BMI is greater than 40 for the last 5 years..thats good??

yes bmi for 5 years of 40 ,,,,or 35 with a co morbid illness like diabetes or high blood presure ,, slepp apnea ect

Wish I could help you. I did the three month diet thing and submitted. So far Aetna has denied me because of the not being over 40 for five years. I have been diagnosed with sleep apnea so I am hoping to get the decision overturned. I don't know if they will reject my supervised diet, exercise and behavior modification. Has anyone sent you the Aetna medical bulletin? Here is a link: Obesity Surgery That spells out their requirements. As near as I can tell you just have to submit and take your chances. Hopefully someone who got approved will respond back.

The good new is that Obesity Law has accepted my file for appeal so I am hoping something good happens soon!

Good luck and will try to answer any questions I can.

MileHigh

I was just wondering, does this apply to the Aetna EPO as well?? or it it just the PPO with all the problems?

Aetna has defined very clearly all of the pre-requisites required for approval of the Lapband surgery. I have every condition described in the guielines: BMI over 40 for at least the last 5 years.

Co-morbidities: Diabetis (diagnosed 2001)

Hypertension (diagnosed 2001)

sleep Apnea (diagnosed 2005)

Atrial Fiberllation/Congestive heart failure

(diagnosed 4/13/2007)

I had my first consult with the Surgeon and the Dietician this week. I started my diet over 2 weeks ago and have lost 24 lbs.

My problem came when I asked my Primary Care Physician for a referal to see a Psychologists to meet the Aetna criteria for a psychiatric evaluation. She called me back and said I needed more of an underlying cause ( ADD, ADHD, Deppression etc...)to write on the referal. She tried to tell me that she could not write the referal by stating it was needed to meet Aetna's guidelines. I told her to put it was a pre-surgery evaluation.

Has anyone else experienced this type of an issue? I have found that getting the right referals has been the hardest part of this journey.

MileHighGreen,

How is the 3 month program different from the 6 month? I talked with Aetna (I have the 'open PPO'-whatever that is) yesterday and they said I have to do 6 months supervised diet and exercise. I'd be all for the 3 month..

If they won't pay for fills, how much are they? Does anyone know?

Fills are priced by your Doctor but are anywhere from $100.00 to $250.00

I have aetna ppo and just had my surgery last week. We did 9 months with a nutritionist before submitting and jumped thru every hoop and just racked up the bills. We figured if it was going to cost us anyway, why not? My spouse will have theirs done this week. They authorized 2 lap bands for us. YAY!!!:clap2:

MileHighGreen,

How is the 3 month program different from the 6 month? I talked with Aetna (I have the 'open PPO'-whatever that is) yesterday and they said I have to do 6 months supervised diet and exercise. I'd be all for the 3 month..

If they won't pay for fills, how much are they? Does anyone know?

As you well know Aetna doesn't answer specific questions. Here is their criteria Obesity Surgery. It lists both the three and six months requirements if they hadn't told you about it. I just got word that my appeal was submitted on Friday. So far I have been denied for reasons other than my 3 month program.

Good luck! If it makes you feel better I have seen of OH that there are worse companies!

Milehigh

How long did you take off of work before returning?

I have just had everything submitted to AETNA and am playing the waiting game. I have seen the dietician and the behavioral health. I have had a bmi of well over 40 for 5 years and have several comorbidities. I am just going to pray for the best. I have an appeal already to go if I get denied. It sounds like they are one of the more difficult companies to

get approval from. pray for me:)

I'm not sure if I'm adding to this thread correctly, I'm new to this site, but I wanted to put in my 2 cents about Aetna. Please bare with me....

I too got discouraged reading some of the threads about Aetna and their approval of this surgery. But after 4 months of a pre surgery diet (Aetna requirement) and 2 months of review they have approved my surgery!!! Yes, they require everything under the sun; At least 2 Co-morbidies, 3 month pre op diet under direction of a doctor & a nutritionist simaltaneously, 5 yr weight history with a BMI at least 35, and current BMI at least 35. It took them a while to approve and they kept asking for more information. The last thing they asked for was the 5 year weight history. I only had documented 3 years. But they accept photos as support for undocumented weight. So with the help of my best friend, who had 2 dated photos (ssshhhh), I sent them and vuala, done. They also will accept a letter from you stating why you do not have the documented weight and what you think you were at the time. That's pretty trusting of them. My BMI was 38.5 when I submitted my paperwork. I'm so fortunate that my company's insurance policy has the Lapband coverage!! Good luck to all those who are on the insurance path to approval and good luck to those that are approved and are having the surgery!!

Wow - that gives me a little hope with Aetna - I think I have a year or two where I don't have doctor's notes regarding my weight. I'm trying to find even Walk-in clinic records that might have my weight on them. Its frustrating!

I mean, I'm fat now, I was fat over the past 2 years...I was fat 10 years ago according to my medical records...what the hell is the difference if I don't know my exact weight in 2003???

I just got my denial reveresed and I am scheduled for surgery on December 20th!

Congratulations!!! I'm so excited for you. Way to stick with it. Aetna hopes for people to quit, that's why they run them through the ringer, to save a buck. But they know this surgery is life saving. Good luck with your surgery on the 20th. YAH!!!! :clap2:

Congrats on your approval. I talked to my doctors' office and they will be sumbitting my husband and my paper work this week. How long does it take to get approval?