AETNA POS LAPBAND TO SLEEVE CONVERSION

[mdonahue4688 2]

Hello Everyone,

Was looking for some insight. I have been having weight gain and some left side pain and have found out that my lapband tubing is disconnected and there has been a slip, I'm most likely going to convert. Does anyone know what aetna requires before a conversion? Thank you!

[Deedee12 1,859]

Hello Everyone,
Was looking for some insight. I have been having weight gain and some left side pain and have found out that my lapband tubing is disconnected and there has been a slip, I'm most likely going to convert. Does anyone know what aetna requires before a conversion? Thank you!

I have Aetna and saw my surgeon April 24th, lapband out May 3rd and my surgeon thought Aetna would still require the 4 months doc assisted weight loss, psych evaluation, nutrition etc. I asked office to still submit surgeon's one assessment and they did and I was approved May 27th for the sleeve. My surgeon required a 6 to 8 weeks between lapband removal and conversion surgery. I am scheduled for surgery in August because of my schedule but could have done it earlier.

Good luck.

PS: Call Aetna yourself and also advocate for not jumping any hoops. They assigned me a case manager that kept me updated about the prior auth status and also called the surgeon's office to tell them what form to fill prior to submission.

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[elcee 3,340]

👍

[mdonahue4688 2]

@Deedee12, the clinical policy for this states for revision approval you need to show compliance with diet and exercise...how did you do that? When I was successful with the band I didn't go to the Dr. very often, and prior to going to see the Dr. who will be doing my revision I hadn't seen someone for my band in almost 1.5 years so I'm nervous I'll get denied despite having tubing that is disconnected, a mispositioned port, and a slipped band. Thanks!

[Deedee12 1,859]

My surgeon was also quite shocked I was approved because she was not aware that their utilization review person submitted. When I saw her for a follow up and she was telling me to set my 4 months appointment with both her and the nutritionist as well as the psychologist and I told her I was approved! She went to go make sure I was not talking about the lapband removal authorization and the insurance coordinator confirmed it and I also had my letter was when she believed it.

Prior to that, I had not followed up with my lapband company (True results) since my 3rd fill with them the year I was banded in 2012. They moved from my area. I just thought I would deal with the band until I couldn't anylonger!

Call your insurance, yell, scream and tell them how the band is unlivable for you, how you comorbidities (I was prediabetic and played it up) was going to get worse and how this is making you anxious. Ask for a supervisor and advocate till they see that you mean it and they tell your surgeon what to submit.

It does help that I am a physician and know the tricks to advocacy and peer to peer but what I outlined is EXACTLY what I did.....And maybe I got lucky. These insurance people are also human beings.

Exhaust your options before you give up.
My surgeon had ONLY 1 documentation which was my consultation Evaluation for the lapband removal. I'd not even done 1 lab work or any other work up!

Good luck!!

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[Deedee12 1,859]

Also, part of why I was so determined to know my fate was to consider self pay options as this is what I did for the lapband. I didn't want to jump through the hoops of daily food logs, nutritionist visits etc and still get denied any way as I had no plans to gain any weight and my BMI barely qualified (had to drink some Water in the office to get to 35).

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[mdonahue4688 2]

@Deedee12Thank you! I don't know quite who to talk to @ Aetna, I was thinking a case manager may be able to help me. I too would just barely meet criteria if just applying for a sleeve as I am just obese, have no co-morbidities.

In the clinical policy bulltetin there are options A-D for repeat bariatric surgery and all of them require "compliance" with diet and exercise program which is hard to show because when I was successful I did not frequently see a doctor for my band. I started seeing a doctor when my reflux started and i started gaining weight. My doctor prefers to do the removal and revision in 2 different surgeries but if there is no complications will do it all in one. My fear is that if i Just get the lapband removed I will be denied for a sleeve. Even without the "compliance records" I feel like with the damaged lapband evidenced by xray and the reflux and weight gain I should be approved for a revision---I feel that with all the research and data out about lapband complications insurance suggesting another band or a band fix is ridiculous!

The person at my doctors office just keeps saying this may be tricky, I want to know from someone at the insurance company what I need to submit exactly to be approved. I have a POS II policy. I don't know who to talk to there or where to start and would like to speak to someone before submission because I know a denial can be difficult to fight.

I am also choosing to go out of network because the previous physician I had seen did not catch all the problems visible on Xray with my band.

I appreciate all of your advice, thank you! If you have any other suggestions I would appreciate it!

Thanks!

Maura

[Deedee12 1,859]

Hello Maura, I tried to PM you but it was saying "module not supported "[emoji57]
Below is my message:
Hello Maura, the name and number of the person who helped me at Aetna is:
Sarah: 959 299 0231.
Not sure if your particular policy will be under her jurisdiction but it's worth the try.
Please keep me posted!
Good luck!

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