Bad news

Well today I got bad news.  Because I choose Aetna for my Medicare plan I need to follow there guidelines not Medicares.  This is a problem.  They are A LOT harder to deal with.

If this where me, the next question I would be asking myself is,"Is WLS ready for me?" Dealing with the insurance comp is only a temporary battle. Using the tool that is given to you after the battle with the insurance company is where all the hard work begans. I fought with United Health for a little over a year.  I asked myself that question. At that time is wasnt for me and I stopped battling.  I worked on my diet, I walked did everything I could and the weight didnt come off. Now 4 1/2 after depending on some wise investment choices I asked myself that question again. And this time yes, its for me. And we are having to fund it ourselfs. I feel blassed to be able to do that. I know many people can not.

Ray   This is not a problem - Its' a hurdle - you can choose to deal with it and jump it, run around it or you can let it block your way - turn around and go back to hwere you came from. You get to make the decision,  My best advice to you is to  call and talk to them  and see exactly what they want , You might ask if there is any way to speed up the process , Maybe your co morbidiities will be able to expedite things ?? cant hurt to ask . another thing to consider is it gives you a lot of time to do your research on surgery adn life after it , get involved in support groups, go to the different functions - Walk from Obesity , The O.H. convention coming on Oct  - you have lots of resources to check out !!

Don't give up Ray!  6 months of medically supervised dieting is just a small nitch on the time line!  A yeara from now you could be at goal weight!!! Guy melt away twice as fast as the rest! Good luck and keep hanging with us!

I know 3-6 months is nothing in the long run.  We have a trip for Disney planned for X-mas this year.  My little girl is going to be 3yrs old and her first time there.  I was just really wishing I would have had the surgery and lost some weight before then. Anyways... This is the info Aetna gave me today:

Selection criteria:

1. Presence of severe obesity that has persisted for at least 5 years, defined as any of the following:

   1. Body mass index (BMI)* exceeding 40; or

   2. BMI* greater than 35 in conjunction with any of the following severe co-morbidities:

      1. Coronary heart disease; or
      2. Type 2 diabetes mellitus; or
      3. Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea); or

      4. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);

   and

2. Member has completed growth (18 years of age or documentation of completion of bone growth); and
3. Member has attempted weight loss in the past without successful long-term weight reduction; and

4. Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary surgical preparatory regimen):

   1. Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet all of the following criteria:

      1. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
      2. Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least three consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.); and

      3. Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records;

      or

   2. Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three months 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:

      1. Consultation with a dietician or nutritionist; and
      2. Reduced-calorie diet program supervised by dietician or nutritionist; and
      3. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
      4. Behavior modification program supervised by qualified professional; and

      5. Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.)

   and

5. For members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, a pre-operative psychological evaluation and clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and postoperative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.

Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB or Lap-Band) experimental and investigational when medical necessity criteria are not met.

I understand how disheartening the criteria looks, but if you let the opportunity slip away because it looks tough you are going to be kicking yourself later.  I always think to   myself how much I would hate to look back and think “what if”.   

I had to face the same obstacles to get approval.  I didn’t look at the time it was going to take.  I just thought that it was my last and best attempt I was going to make at losing weight.  When I started I also went and seen a psychologist.  I figured the more people I seen, the better!  I had two psychologists, two doctors, and a nutritionist that wrote letters supporting me.  I was still totally astonished when I got my approval this month!  I’m really still questioning the approval.  I probably will until they put my under to do the surgery.   

I also found a lot of hope and help in the people right here that have gone year after year fighting for approvals.   

I can also relate to hoping to have surgery by a certain date!  I wanted to have my surgery before I started the nursing program.  That was nine months ago!  I planned and worked and then in the middle my doctor retired.  That sent me into a spin for a while.  Then getting through test after test to submit and be denied because I needed yet another test.  I was pretty much a let down at every turn.  I did what they asked and kept pushing forward.  I think that’s what you should do.  If you have to freak out and vent once in awhile then go ahead!  There are many times I ended up setting in the shower floor crying.  The showers a good place because the kids couldn’t hear!    

The funniest thing that I ever received was the quote at the end of my messages.  I got it in a fortune cookie about four months ago.  I keep it in my wallet now and it some how pushes me forward when I feel at wits end. Go with your heart, and don’t ever say “what if”!  

Not to discourage you but from my understanding Aetna is one of the hardest and longest ins companies to get approval from. Their criteria is much more then others. I almost choose them for my Medicare Advantage Plan this year. I wasn't contemplating this surgery. In Oct. when the new plan info comes out depending on where you are in Aetnas process I would maybe take a look at some of the others plans and consider switching in January 2008. My sister had limited co-morbidities and Aetna wouldn't even consider her. They seem to want a whole lot. I went with Secure Horizons who only took my PCP letter, a letter from a nutritionist I had been seeing for about 9 months and the Psych eval. I had a whole nice package put togethr with a couple years of labs, weight loss programs etc and they didn't want any of it and I was approved in 1 week. I was shocked. Just giving you some things to consider. Jeanne

Ray  Don't give up!  You can do this. You really can.  I came from California  almost 2 years ago. MY Husbands insurance would pay for the surgery, juts my co-pay and I had it.  they wanted me to jump through some time consuming hoops and I looked at the list and thought no way I can do this!  So I backed out.  Here in AZ My husband wont cover it period. 4 years later and about another 30 pounds, I am now a self pay.  I wish I had done it then.  Don't regret Ray, just do.  You can be strong and jump those hoops and sooner then you think you will be on the way!

I struggled with my insurance for over 2 years!  When I got discouraged, my husband was my cheerleader and would not let me give up.  There are so many people here to help you through this.  I know, they sure helped me.  Now, I have been home 2 days since my surgery!  Wow! Remember, this is not a stumbling block...only a stepping stone. Good luck to you and God Bless. Robin

Keep your chin up.  I had to go through all of that hoopla and was lucky enough to finally have the insurance company say yes.  If you are serious, keep tryng.  I dealt with a specific group who specializes in the Lap band surgery and they were very helpful in getting what i needed together for the insurance company... Good luck.