Aetna makes a change

Alexandra · August 31, 2003

Wow, this is NEWS for Aetna folks. Aetna has changed its Coverage Policy Document on bariatric surgery. It doesn't actually embrace lapbanding, but it DOES open the door for people who have significant contraindications for RNY. There are some contraindications listed, but as we all know they can't possibly predict all the cases. For example, if I were going to try to appeal my denial again now, I'd make a strong case that the rapid weight loss following RNY surgery was in itself something I could not accept. That sort of rapid weight loss significantly disrupted my life 13 years ago, when I lost 75 lbs in 12 weeks on Optifast.

For the full picture, visit Aetna's website at www.aetna.com and look for Coverage Policy Bulletin # 157. I see more Aetna bandsters in the future!! :rolleyes:

Ginger2120 · September 2, 2003

When I first started the approval process for my lap-band with Aetna they were denying sayting that they do not cover the Lap-Band under any circumstances. When I finally got approved they said it was because I was an "exception" to the rule because of specific medical conditions I have.

My advive to anyone fighting with Aetna is to keep on them. Eventually they will fold and approve you, it just takes time. I went through a lot of frustration with them but now I'm finally going to be banded in September 22, 2003 and I can't wait!

Good Luck!

jOANNE · September 21, 2003

My company is changing their plans to either Aetna or BCBS. I understand from your message that Aetna has made some changes.

Do you know what I would need to do to get approval?

BMI 50

High Blood Pressure controlled by medications

I do have bouts with Ulcerative Colitis.

no other co morbities besides sore joints sometimes

Alexandra · September 21, 2003

Ginger: Tomorrow is the big day!! Good luck, and don't forget to come back and let us know how it went!!

Joanne, it sounds like you would easily qualify for weight-loss surgery with either Aetna or BCBS. Here's what Aetna has to say about the band:

Aetna considers open or laparoscopic vertical banded gastroplasty or laparoscopic adjustable silicone gastric banding (LASGB, Lap-Band) medically necessary for members who meet the selection criteria listed below (the usual yada-yada) and who are at increased risk of adverse consequences of a Roux-en-Y gastric bypass due to the presence of any of the following comorbid medical conditions:
Hepatic cirrhosis with elevated liver function tests; or

Inflammatory bowel disease (Crohn’s disease or ulcerative colitis); or

Radiation enteritis; or

Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma.

From this it seems that you could qualify for the band with Aetna. Your PCP and surgeon would have to really home in on that in their recommendation letters--they'd have to say you're NOT a good candidate for RNY for medical reasons.

Good luck!!