Has anyone had lap-band covered by Aetna? I'd welcome any info on what your process with them was.

Hi Geri,

Aetna did pay for my lapband, but only after I took my appeals to a third party arbiter who overturned their denials. This was back in early 2003 and at that time Aetna was denying the band flatly, saying it was investigational. Now they've changed their tune somewhat, and if you look on their website you'll find the document that explains the circumstances under which they will approve banding. Have you done that? And do you know whether your policy covers bariatric surgery at all?

I'd be more than happy to share the details of my experience, but they may not be at all relevant to you. How much do you know at this point about your plan and what it covers? Do you know if you qualify medically for surgery? Is your doctor in the network? There are many questions to be answered and my experience just may not be any help. But I'm glad to share if it will.

Hi<

I have Aetna and have been fighting with them to approv my Lap band.

they are no budging,it seems they come up with a new reason that they can deny me every time I turn around.

I have just gone ahead and hired a Lawyer. I hope that will work out for me. he said he is sure I will get the band.

If you ever want to talk let me know.

Amy

Hi I did a search of Aenta and read this post. How did your case turn out? Did the lawyer help alot? Who was he and what did he do? Right now I'm about half way through Aetna's pre-op reqirement, which for me is three months of supervised excercise and nutritional counceling. I haven't been denid yet but since my bmi is only bout 37-38 I'm expecting the worse. If I am denied I'll definatly get legal advice.

thanks

Randy

I did not have any problems with Aetna, which surprised me since I had problems with them when I was doing my IVF treatments/drugs, which they covered, but were being difficult. Like we cover the drugs but only of your Dr. injects them, yeah right, my Dr. is going to open at 8 pm (optimum time) to give me a shot! Finally, they came around and all went well.

I began my LB approval process with Aetna in mid-July and was approved after testing, psych, cardiac etc... on 9/6/06. We have a PPO policy which does not exclude WLS. My out of pocket is $500 and then ins kicks in at 100%. Also, since my fills will be done at the surgery center they are treating these as a procedure and will pay for them. I am scheduled for surgery on 9/28 with Dr. B.

When speaking with Aetna I asked how long the approval process would take and the rep said I would not have any problems getting approved. My husbands company is a large pharma and they have specific Aetna reps that work with the employees (maybe this helped). She did mention that not all policies are written the same and it just depends on what your company selects to cover.

Good luck with your getting your approval. Just be persistent and it will work out.

Dear LB927,

I'm a new user to this site and I've been crusing thru the forum and came across your message. About two weeks ago my PCP suggested that I consider the LB procedure. Initially, I was dead set against it but now I'm seriously considering it. I'm 42 yoa, 5'5", 218 lbs w/ a BMI of 37 (I think). I have several co-morbitity's such as extremely high blood pressure and have just recently been discharged from an ICU for chest pain. I've been on several medications for it but it's still not good, currently it's 150/100. It's been as high at 200/170. During the past 16 years, I've tried many, many weight loss programs (WW, JC, Atkins, nutritionist, personal trainer, etc.) - I have proof of a majority of these things.

Anyhow...I'm feel I'm at my wit's end and am now really considering this procedure. I, too, have Aetna and was really surprised to see how fast you got approved compared to all the other postings. Can you offer any advise as I begin this process? I wish you the best of luck; I hope you'll be up to logging on during your recovery period. I'd enjoy hearing how you'll be progressing.

ok here goes i have Atnea and i just found out they cover lapband so i called my pcp she gave the referral cause i have HMO i found a doctor now i have an appt with him on the 10 of november i meet with him the nurse, diet lady, insurance rep not sure how long i will have to wait until atena approves it. i have no diabetes or sleep apena or anything like that i'm not crazy or least i think im not. and everytime i call Atnea they are always very nice i just wonder if they will give me the run around. i just found out also that we are switching in Jan to another carrier CIGNA WTF!!!!

when i meet the the doc im going to be straight up with him and say i want this done before christmas or right before jan.

I currently have Blue Cross Blue Shield which excludes Weight Loss surgeries, so my next option is to sign up for Aetna through my husbands insurance which says they cover Bariatric Procedures. Before we sign up which costs $200.00 out of pocket monthly, i wanted to make sure Aetna covers Lap Band. I will be calling Aetna in the next couple days to ask questions. Please see my following questions and let me know if there is anything else I should ask?

q How long do I have to be on insurance before insurance will cover Lap Band?

q What % will Aetna cover for Lap Band?

q Does is cover pre-op (Psych testing, sleep Study?)

q Does it cover follow ups-check ups?

q Does it cover fills?

q Lead time, what does it take to be approved for this procedure?

I have Aetna and I found them very easy to work with. I called them and made sure that my company's coverage included the Lap-Band (Aetna has been covering it since the end of March but not all employers allow it). I then began a 3-month multi-disciplinary program supervised by my PCP and a registered dietician (all covered by Aetna except for copays) while I searched for a surgeon. I selected a surgeon about 2 weeks before I completed the multi-disciplinary program and his office coordinated with my PCP from that point forward. The surgeon's office requested approval; my PCP forwarded all of my records to the surgeon who forwarded them to Aetna. Aetna came back with one question and approved me within a week. I had surgery 2 weeks later.

Aetna did not cover the psych evaluation required by my surgeon ($1000). My surgeon is not in network so he will bill me for some portion of his $5,000 fee. The hospital ($10,000) was covered completely. I suspect that I will be out of pocket about $3500 when all is said and done. I would have paid myself otherwise so its still a great deal as far as I am concernced.

Pugmaster seems like you gott it under control i guess im just a bit on edge because my company is changing to cigna in January 07 so im trying to get it done before the year is out do you think that is possible

Tia, The thing with Aetna seems to be to make sure that you do everything they require. Duh! You need to take a look at their Clinical Policy Bulletin #0157. It spells out pretty clearly the "Selection Criteria" (i.e., the hoops you have to jump through) for bariatric surgery. I read it and figured out what I needed to do to qualify in the shortest possible time. Unless you have 6 months of physician supervised diet in the last 2 years (I did not), I don't see how you can qualify in less than 3 month.

I DONT WANT TO GET ANOTHER DUH FROM YOU SO I'LL READ OVER OVER AGAIN LIKE I'VE BEEN DOING AND KEEP MY PEOPLE POSTED GOOD LUCK ON YOUR JOURNEY:paranoid

Tia, Truly sorry if I offended you.

The "Duh!" was a commentary to myself on the obviousness of what I wrote...as in "I can't believe I just wrote that! Of course you have to do what they require!" It had nothing to do with you.

Next time I get the urge to critique my own writing, I'll just backspace and start over.

Good luck!

we are still cool :rockon: my appt is coming up on the 10 so hopefully :pray: i will have approval from Atena right afterwards and yes i did follow all of the requirements in advance. :kiss2:

I fought with Aetna for 6 years. Lots of tears and work. I kept a folder of everything that I did. I was told that your best bet would be to have a problem with internal scarring that would make the bypass a bad thing to have. I had this from previous c-sects. Also letters from people who have worked out with you and I even sent pictures of my exercise equipment. I had 3 doctors send in a recommendation letters for me. I asked alot of questions from people that did get approved and that was alot of help. I think I am the only person with Chevron that was ever approved. So If I can help I will do what I can to help. I was banded as of Monday the 23rd. It was pretty uneventful. I have slight pain. The only thing that bothers me is My pupils are dialated and so now I have to see and eye doctor, but otherwise I am doing well. Good luck to you on your journey.

I have Aetna....First appt. with surgeon was in June, went through "the hoops", surgeons office sent paperwork in for me. After about 3 weeks I was denied....said I had to prove I had been overweight for more than 5 years and one more month on the dieticians 3 month evaluation. Hopefully I'll get all my sign-off papers from the dietician and PCP this Friday and get started on the appeal. I'm hoping for a December surgery, fingers are crossed! Anything else I can tell ya just let me know!