AETNA INSURANCE HELP!!

I have Aetna HMO with an Exclusion for WLS surgery. I had an RNY done in 2000 under another insurance and unfortunately have gained most of my weight back. Before my surgery I had Diabetes one of my co-morbilities and am headed back in that direction with my weight gain. I want to have a revision and unless there is something wrong from my previous surgery my insurance won't pay. I was told there is a statute of some sort that states that if you have diabetes that no insurance can deny you any surgery. I need to get the information so I can fight with my insurance company. Can anyone tell me how I can get this information?? PLEEEEZ any help would be appreciated!!!

Unfortunately, if your employer did not purchase the rider/benefit for weight loss surgery, Aetna can and will deny you - diabetes or not. Do you know that something is wrong with your previous surgery? Have you had an upper GI and a consult with a revision surgeon? Or are you just assuming that something is wrong because of weight gain? If it is the latter, remember that you still have the tool. Go back to your pouch rules and see what happens. HTH, Kristen

Thanks for your reply Kristen. I have had a consult with a revision surgeon and am in the process of getting an upper GI scheduled to see if anything is wrong. I was looking further into the Aetna web site and found that Aetna considers it medically necessary if the primary procedure was successful prior to pouch dilation and the member has been compliant with a prescribed nutrition and excersise program following the procedure. Where I went to was www.aetna.com/cpb/medical/data100_199/0157.html My question to you then since you seem to know what your talking about, with the exclusion on my insurance if I have a pouch dilation would my insurance cover it then?? Also you speak of pouch rules and am not sure exactly what that means, could you tell me exactly what they are? If in my case I have just stretched my pouch out and am not able to have surgery done if the insurance won't pay for it, is it possible to make the pouch smaller by just eating less at this stage of the game?? Thanks so much for your help! I am still praying that I can find a way for the insurance to pay for a revision!!!!!!

Hi Marcia, Yes, Aetna does consider it medically necessary *if* and only if your policy has a benefit. You will want to call Aetna and ask them specifically if you have a benefit - is the revision excluded even if you meet the medical policy bulletin criteria? If yes, ask then if it is still excluded if medically necessary. If the answer is still yes, then I am afraid that you don't have much hope of Aetna paying. As far as the pouch rules, they are preprinted on my OH profile (at the bottom). Following the pouch rules (and water loading) could really help. HTH, Kristen

Kim I  haven't had a chance yet to check with the insurance to see if they will cover if it is medically necessary. I was still wondering.   I got your pouch rules and looked them over.  Does this work even if I have stretched my pouch out,  and if I followed the pouch rules would my pouch shrink again? I have gained alot of weight so my pouch is probably stretched but I am also told I have no metabolism (partly why I have gained weight I am sure) as I also have a very low heart rate. 

You may want to post your question on the insurance board, if you haven't already. Good luck to you!

Yes I did post there also! I need all the help I can get Thank you!!