Denied by Aetna POS II

[sks_sleeved 0]

Even though I told my doctor’s office it seemed like I couldn’t have a net gain they assured me it would be fine. Low and behold I was denied for a 5 lb net gain. I am 250 currently at 5’6 and they have suggested I do the six months again and this time just stay at 250 to ensure I am at 40 BMI since I only have mild sleep apnea and no other issues. My question is—at the end of the new six months will Aetna deny me bc I still didn’t lose the original 5 lbs or should I get back down to 245 even though that puts my BMI at 39.5? We considered doing a peer to peer and having the doctor say Water weight etc., but felt it would be better to do six more months which is really only five based on counting April’s weigh in. Timing actually works out on my favor with surgery now I’m Sept, so I’m not worried about that, but I don’t want to get to September and be denied again.

[Chrisb428 626]

I have Aetna and I have heard they do this alot. Its my worse fear! If you are restarting the 6 mos i wouldnt think they could hold that 5 lbs against you. Your current weight should be your new starting weight i would assume. I would do the peer to peer, I dont have the patience you do...lol Good luck whatever you do!

[336Mike 549]

You can look up the clinical policy bulletin on the Aetna website and read the details for yourself. That should help you understand the policy. Don't get caught up in speculation. You can always call and ask to have it explained to you as well.

VSG 10/11/17
HW = 360
SW = 292
GW = 220 3/7/18
CW = 206.6 @ 6'5"
153.4 pounds gone! [emoji256]

[BGrundee 61]

I have Aetna and just had my surgery 5/11. Aetna is serious about the no net gain. My weightloss coordinator at surgeon's office made that very clear. I had to do the 90 day ( 3 months) and actually gained weight also, but my WLS coordinator told me to do all I could do to have no net gain and come in 1 lb less than my original weigh in. Between my 1st weigh- in and 2nd weigh- in, I was going through a very stressful rough time and unfortunately gained alot of weight. See my stats below. With weigh ins the only two that count is the 1st and the last. Also sleep apnea regardless mild or extreme is still sleep apnea ( I did not have a 40 BMI to get approved for initial consulation. I got approved for initial consultation with bariatric surgeon after I had a sleep study test, which showed I have mild OSA and help of DMHC to overturn Aetna 1st denial) Aetna loves to deny so its important to follow the instructions to the T. I only had two shots lefts to lose weight and went gung ho on a crazy zero carb plan, and did a boat load of cardio to drop weight. I even took Water pills 2 days before weigh in to shed any water weight. Do what you have to do to make sure you come in under 1 pound than your initial weigh in

The purpose of the regimen is to show you have control and Aetna wants to see this control. FYI You don't have to maintain 40 BMI after the regimen to get approved for surgery because obviously you were a 40 / + BMI when approved for initial consulation with your surgeon.

1st weight in 197

2nd weight in 212

3rd weight in 199

4th weight in 193

If you start over, your weight will be the new weight...Like in a previous reply, I would have a peer to peer and ask your surgeon to explain it is water weight or something.

[Jendkopp 62]

@BGrundee: so you got approved with a BMI under 40 and mild sleep apnea? did your dr have to do a peer to peer to get that approved?

[BGrundee 61]

3 hours ago, Jendkopp said:

@BGrundee: so you got approved with a BMI under 40 and mild sleep apnea? did your dr have to do a peer to peer to get that approved?

Didn’t have to do a peer to peer. After I completed 90 day multi disciplinary regimen, I was approved for surery 10 days after all my paperwork was submitted.