Aetna POSII

IURN62 · January 20, 2009

I have Aetna POS II and i called this morning and they said they do not cover the surgery. Is this due to my employer? Im very let down and tired of feeling bad........do i give up? I qualify for the surgery because of my weight but am ready to give up.:wink2:

mountainmomma · January 20, 2009

My husband was going to switch us over to this Ins , I had him call and see if the surgery would be covered and they said NO. So we had one day left to switch back to Humana, which does automatically approve the surgery now if you are at least 100 lbs overweight. No waiting or anything. I had a feeling my surgery was going to get pushed out to Jan so we switched back just in case.

It is not your work that causes this it is just the INS company that will not cover it. If you can go to another company for INS it will be worth it, but check the coverage first. I got very Lucky . Longer story but lets just say I only had to pay about $300 total for my surgery. Mind you est costs were $33K.

IURN62 · January 20, 2009

Thank you momma for your reply. Yeah it looks like they dont cover it and paying 30G out of my pocket is not an option. I guess the lesson is just because you have a certain insurance, you need to call and find out if your employer includes the banding in your plan. Im down but not yet out. I will get this weight off one way or another.

Thanks Momma :thumbup:

KyBandChick · January 20, 2009

I would have to disagree with the above poster. It actually has a lot to do with your employer and the plan items they have chose to cover. I too have Aetna POSII and was covered for surgery tomorrow. I think you will find if you do enough research you will finds tons of people with this same insurance that cover and don't cover the surgery. The name of the policy doesn't mean everyone's coverage is the same. My employer is actually self insured and must use an insurance company to "front" their coverage. Look at your policy exclusions does it all out exclude weightloss surgery or does it exclude the surgery unless you meet certain requirements. My policy excluded the surgery unless it was approved by a Aetna director. See the below link to Aetna's policy for weightloss surgery. While your first answer my have been they don't cover the surgery sometimes they actually do they just don't tell you that part (you really have to read your exclusions that your HR department should be able to give you).

Obesity Surgery

Hope this helps. I have found the more research I did the more I learned about the game that is insurance approval. Don't give up. Is self pay via financing an option if you are not approved?

mountainmomma · January 20, 2009

Yea It is alot of $ out of pocket, Maybe talk to the Dr you have chosen and see what your options are. Don't get the new car. Get the band or whatever you decide to do,FYI the one that is advertised here is not a good option if you are trying to save money, esp if they do not have a Dr in your area.

It took me 14 years to make the decision. Good luck and let me know what happens. My email is somewhere on here.

~~Beth~~ · January 20, 2009

I have to agree with KyBankChick, I also have Aetna POSII and just had my surgery completed on 12.30.08 granted I had to go thru the detail of six months, and alot of paper work, but they approved it with out any problems. They try to frustrate you because it is very pricy, but don't give up, start at the bottom - by reading the exclusions.

good luck - and don't give up

mountainmomma · January 20, 2009

I agree with you guys too, unfortunatly I had less then a day so no time to make those kinds of phone calls to dig for that kind of information, Big companies have deadlines for insurance renewals at the end of the year and I was already panicky over all the other stuff that was going on, last thing I wanted was to go off on some poor phone bank person at the INS company. But yes you are correct in the fact that you have to dig deep, but if your Dr has a patient advocate they can help alot.

IURN62 · January 20, 2009

Wow maybe all isnt lost. I will take your advise and look go to my HR department. I will keep you posted and thank you so much for your help.

:thumbup:

KyBandChick · January 20, 2009

One other thought. I can't tell where you live but are you sure the $30k is the best price in your area? That seems really high. I have seen several threads where people discussed price and my self pay (If I had to pay) was the higher cost of $17,500. Paybe attend a few seminars if you have't already as they are usually really good at helping with insurance and advice on self pay.

IURN62 · January 20, 2009

I am in Chicago and im going to a seminar Saturday. I just talked to my HR dept and they dont have the exclusions, but she told me that if i have another underlying issue (i have sleep apnea) that it should be covered. I am going to wait until i speak to someone at the seminar before i call Aetna again. KY did you have your surgery or are you going tomorrow?

mountainmomma · January 20, 2009

Keep in mind this $33k was for all of it, we are talk anesthesia and the hospital room and all that stuff, I had already met my deductible and out of pocket was all I had to pay and it was only $300 which was less then the 20% I would of had to pay had I not done all the rest. It would of been around $6k for me. According to the Dr the band itself is a very expensive piece , yes I live in Austin Texas and things have a tendency to be a little pricey here, But I was not going to go out of the country or state for that matter and My Ins had already approved it without a waiting period or anything, I just got Lucky all the way around, I am Not going to complain.:thumbup:

FYI My Dr was awesome!!

IURN62 · January 21, 2009

Well some good news from my company. The lapband isnt covered but i can file and appeal with Aetna due to my medical conditions. I do have sleep apnea and GERD. So fingers crossed and wish me luck. Thank you all for your input here, i will keep up the fight.