Aetna questions

[BG0103 0]

After starting the process almost 3 years ago and then bailing due to husband's sudden health issue I find myself here again.

I'm back to considering the VSG. My insurance covers it (Aetna) but I'm reading stories of people being denied because their weight history has an occurrence of a BMI under 35 in the past 24 months That would be August 2018 for me

After putting off surgery my Dr. put me on Vyvanse. It worked for a while and at one weigh in my BMI reported at 34.8. Problem is, I self-reported my height all of these years and I'm actually an inch shorter than I thought I was, I guess that's Water under the bridge. If I had let the Dr. measure me I never would have been under 35 BMI. I have sleep apnea and use a CPAP.

Has anyone been denied because of this? I mean, the weight came right back at the next 3 month checkup. I stopped the meds and am now at my highest weight.

[GradyCat 3,692]

My BMI was under 30 but I had the comorbidity of sleep apnea and I was approved. Of course it wasn't Aetna.

[BG0103 0]

1 minute ago, GradyCat said:

My BMI was under 30 but I had the comorbidity of sleep apnea and I was approved. Of course it wasn't Aetna.

Thanks! Aetna clearly states 35 and over BMI but at only one time during the year would my weight have been under at a 34.8. The test or the reported weights that year are over 35 BMI. Of course I self reported as an inch taller than I actually am. I guess I seem taller to myself

[3sonsitk 16]

Same situation here. My authorization was sent to Aetna today so we’ll see. Fingers crossed for an approval.

[BG0103 0]

Best of luck, keep me posted. If everything works out for me I’m looking at a May surgery.

[3sonsitk 16]

I’ll keep you posted

[3sonsitk 16]

On 2/4/2020 at 5:24 PM, 3sonsitk said:

I’ll keep you posted

I received the call that Aetna approved me. Surgery scheduled for 2/27. With that said, my BMI was less than 35 for the pst 2 years with no comorbidities until my PCP ordered a sleep study that shows I have mild sleep apnea.

Edited February 7, 2020 by 3sonsitk

[BG0103 0]

Wow, that was a super fast turnaround and great news for you! Congratulations! That alleviates my fears a little.

there’s a woman in another bariatric group that I’m in that just had Aetna deny her claim because they wanted five years of her weight history instead of two. Isn’t it strange? I totally think it’s just up to the whim of the person reviewing it.

[GrungeGrownUp 10]

I have Aetna and just got my referral from my Primary to the surgeon. I am hoping Aetna doesn't give me issues. My BMI is 43. I do have sleep apnea as a co-morbidity. At what point does the surgeon get the approval from Aetna?

[BG0103 0]

3 minutes ago, GrungeGrownUp said:

I have Aetna and just got my referral from my Primary to the surgeon. I am hoping Aetna doesn't give me issues. My BMI is 43. I do have sleep apnea as a co-morbidity. At what point does the surgeon get the approval from Aetna?

The surgeon typically submits for approval to insurance once your three or six month nutritional visits have been completed along with any mandatory testing.

[GrungeGrownUp 10]

2 minutes ago, BG0103 said:

The surgeon typically submits for approval to insurance once your three or six month nutritional visits have been completed along with any mandatory testing.

So I have a way to go being as my first nutritional visit was today. Can anyone tell if I am reading this correctly? I have to do 3 nutritional visits?

• Multi-disciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multi-disciplinary surgical preparatory regimen of at least 3 months (90 days) duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member’s ability to comply with post-operative medical care and dietary restrictions

[BG0103 0]

3 minutes ago, GrungeGrownUp said:

So I have a way to go being as my first nutritional visit was today. Can anyone tell if I am reading this correctly? I have to do 3 nutritional visits?

• Multi-disciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multi-disciplinary surgical preparatory regimen of at least 3 months (90 days) duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member’s ability to comply with post-operative medical care and dietary restrictions

It depends, is your surgeon an IOQ with Aetna? If so they will have the three month program. Aetna is very specific about IOQ’s and some policies will not cover at all if you use one that is not an IOQ.

The 3 month is the fastest way. It typically comes out to 4 months. Your first meeting with the Bariatric team and then your first nutrition appt is typically scheduled after that.

Edited February 19, 2020 by BG0103
Misspelling

[GrungeGrownUp 10]

4 minutes ago, BG0103 said:

It depends, is your surgeon an IOQ with Aetna? If so they will have the three month program. Aetna is very specific about IOQ’s and some policies will not cover at all if you use one that is not an IOQ.

The 3 month is the fastest way. It typically comes out to 4 months. Your first meeting with the Bariatric team and then your first nutrition appt is typically scheduled after that.

I checked on Aetna's siteand Advent Health Celebration is not an IOQ, but the surgeon is in network for me and listed under their in network bariatric surgeons. The only hospital that is on the list has one particular surgeon that 2 of my coworkers (very large employer) have been to and both have said while the surgeon is ok, the office staff is terrible. Both recommended I go elsewhere. My plan covers the whole Advent Health System.

[BG0103 0]

59 minutes ago, GrungeGrownUp said:

I checked on Aetna's siteand Advent Health Celebration is not an IOQ, but the surgeon is in network for me and listed under their in network bariatric surgeons. The only hospital that is on the list has one particular surgeon that 2 of my coworkers (very large employer) have been to and both have said while the surgeon is ok, the office staff is terrible. Both recommended I go elsewhere. My plan covers the whole Advent Health System.

I’m in a lot of Bariatric groups and there have been several who have gone through an in-network surgeon and have been denied and had to start over because they didn’t use an IOQ. I would call Aetna just to be clear in what their requirements are. Mine will only pay 70% if I don’t use and IOQ and I would have to do the 6 month nutrition. I know it’s clear as mud lol but you definitely want to know ahead of time!