Seeking WLS Grads Experienced with Aetna EPO Coverage

mmorrison49320
on 2/15/07 1:13 pm - Apopka, FL
Hi, I have just finished 6 mos. of my PCP monitoring of my weight and today we have begun the approval process. My insurance is Aetna EPO, and I am hoping someone who has gone thru their process will be able to educate me on what lies ahead for me as I seek WLS approval/coverage. FYI, I have no cardiac, blood pressure or endocrine (diabetes) problems. I was evaluated as having moderate sleep apnea, chronic back, knee and foot pain (severely limiting exercise options), my BMI is 50, weight is 294, height 5'3". I also have family history of h. pylori bacteria resident in my stomach, as well as GERD. And my paternal grandmother (whom I never met) was a WLS pioneer in 1959. She was around 300# and had some sort of bariatric surgery the year before I was born. Judging from pics I have seen of her taken around 1977, she might have weighed 120. My dad is also severely overweight, though he wasn't when he was younger, and I have been overweight most of my life (exception: first 3 yrs. I was married). I have a co-worker who was 460# and is now probably 175 after WLS and he's mentoring me, as well as referring me to another lady to get a "girl's perspective". His surgery was done at Shands at Univ. of Fla. Gainesville, but I am looking at Celebration near Disney. Dr. Kim is the lead surgeon there, I believe. Thanks to anyone willing to help me with some info!! :thumbsup: Michele
Lexa321
on 2/15/07 9:32 pm - weston, FL
i dont have aetna... but im sure you could call them and see what that need.... good luck with everything! i know you will do great! lex
Lindsay39
on 2/16/07 9:31 am
Hi Michele, I have Aetna and just had surgery Dec. 13th. If your surgeon's office has competent insurance reps, I would leave everything in their hands. They know how each insurance company works and what each requires, as well as knowing just how to phrase things for that particular insurance company. I learned that if you contact Aetna, they will start a file on you immediately and basically try to find ways to deny your surgery. I was lucky and had great reps at my surgeons office, but I also had unbelievably detailed monthly logs for Aetna. I followed word for word what my surgeon's office told me to do. Aetna gave me erroneous info. for over 6 months, and only when I went solely by my surgeon's directions did I finally get approved for surgery. I will tell you that I did not have any co-morbidity factors, and still got approved. I wish you luck!
Kristen H.
on 2/16/07 9:48 am - Orlando, FL
Hi Michelle, I have Aetna. I had to file suit against them for surgery (they paid). The complete clinical policy bulletin for obesity surgery is located at http://www.aetna.com/cpb/medical/data/100_199/0157.html As soon as you have completed all of your "Aetna Hoops" and the data has been submitted to the office, Amanda and Jennifer will submit you to Aetna. Insurance generally has *up to* 30 days to respond. FYI, I am the former office manager for US Bariatric Orlando (I start my new position - Bariatric Patient Concierge - with them on Monday! Now instead of copier contracts and ordering paperclips, I get to work more closely with patients and their journey towards surgery. But more importantly, I had RNY surgery with Dr. Kim in Oct 04, before I was an employee. I cannot say enough good things about him and his surgical gift. If you have any specific questions, I'll be happy to chat with you. HTH, Kristen
Mirabelle
on 2/17/07 3:58 am
Kristen, Congrats on your new position. It sounds very interesting. Good luck. ~Ginny
Mirabelle
on 2/17/07 4:01 am
Hi Michele, I am no help with Atena but wanted to wish you good luck.
mmorrison49320
on 2/17/07 10:44 am - Apopka, FL
Thanks, everyone, for the info. This is one place where I KNOW everyone understands how I am feeling, and I hope to return the kindness to others in the future. Kristen, I read your blog tonight (oh, well, Calculus homework can wait ;-)!) and I see you've been thru quite an ordeal. I would appreciate the chance to email and speak with you off-forum, if you'd be willing to do that. I may have even spoken to you before. I have called US Bariatric several times in the past, actually starting about 2 years ago. I finally got around to weight loss monitoring with my PCP in Sept. 06, although I've been looking into this surgery for going on 5 yrs. I hope to be speaking with you soon! :-) Michele
Luvitsunny
on 2/19/07 6:01 am - Sunny South, FL
I can't give you any answers about Aenta but I think Dr. Kim was with US Bariatrics in Fort Lauderdale when I had my surgery 12-15-03. He is very, very nice and to be a part of that group....he had to be a fantastic surgeon.
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