ALL AETNA INSURANCE MEMBERS ...PLEASE SHARE

Hi, I am fairly new to this board so I am still checking out some things. If any of you have Aetna Insurance and have been trying to get approved for WLS would you please share all of your experiences, i.e, approvals how long it took, denials, appeals. I sure would appreciate your comments. Jean Anderson Omaha, Nebraska

Hi Jean, Welcome. I am in the same boat as you, so I am looking forward to any responses you receive. I have Aetna PPO and have completed the 3-month multidisciplinary program per policy 156 (that should be correct) for bariatric surgery. My doctor should be submitting my documentation any day, so I will let you know if all goes well. I am nervous -- scared I will be denied. Best of luck in the process.

your are fortnate, u live in california, your final appeal is the california insurance commision who has a record in favor of overturning Aetna more often infavor of the claiment on appeal, espescialy when properly prepared such as with a attornies  assist, such as what obesity lawyers offer.  They have even on rare ocassion granted the DS.

I have Aetna and I did the 3 month multidisciplinary surgical preparatory regimen. I went strictly by the cpb's listed on Aetna's site for obesity surgery. Part of the multidisciplinary surgical prep consists of a diet monitored by a nutritionist. I did weekly visits for the first month and then every two weeks. I followed the cpb for weight loss programs for the diet. Since I was a borderline 40 bmi I was depending on co-morbidities to gain approval, I followed their policy for a low calorie (not very low calorie) diet. I believe this helped validate my co-morbidities by following the cpb's directions for those with co-morbidities. The cpb directed patients with co-morbidities who were on a low calorie diet to be seen weekly by their surgeon/doctor/physician' assistant for the first month. So for 12 weeks I saw the nutritionist and the PA weekly the first month and then every two weeks I saw the nutritionist and I saw the PA monthly. The nutritionist had me document my meals in a notebook daily and also document my exercise daily. Aetna paid their part for both the nutrionist and for each doctor visit. If you are on any psychological drugs, you must also be seen by a psychologist or psychiatrist for evaluation before submitting your paperwork for approval. If you do not have a history of emotional problems or a history of taking anti-depressants, you do not have to have a psychological assessment. I recommend that you go to Aetna's site and do a search for CPB and look up their requirements for Obesity Surgery and for Weight Loss Programs. Also, I would recommend that you have a thorough diet history to submit. Even if you do not remember, try to come up with one. I also scanned some pictures of myself that were taken throughout my life to turn in with the paperwork as well. It does not hurt to have pictures of close relatives that are obese as well. I also wrote beside relative's pictures their morbidities and co-morbidities as these tend to run in families. In addition, I also spent part of an afternoon gathering copies of my medical records from my physicians, gynocologists, etc. The more you are able to turn in, the better you will be. I also called several times and talked with Aetna's Member Services about any questions I had. This really helps you out as Aetna documents every call you make and what the call was about. If you do call Member Services, ask the person you speak with for their first name and the first letter of their last name. Note the time and date you spoke with that person and what the call was about. Many times I was told different answers to the same question from different Member Services personnel. I worked very had on the surgery as I knew I was the only person that it really mattered to. Since Aetna did not have a surgeon in my area that did obesity surgery, I was able to get a great doctor who was not in my network approved to be paid at the in-network rate. The best part was that since the doctor was not a participant with Aetna, Aetna will be paying 90% of the billed/actual charge and not just 90% of the reasonable and customary. The paperwork was submitted and I was approved within a week with no denial hassle. Just study up on their requirements and hold them to it. Good luck!

Hi, I just saw your post....I was denied by Aetna today so I need to do the 6 month weight loss - how did you know how often you had to see the nutritionist/doctor?  I didn't see that in the Aenta paperwork - also - I do not have the comorbitities and my BMI currently is 41.8 and if I lose weight over six months - it will fall below 40 if I only lose 13 pounds in 6 months I will still be 40 BMI - I am so confused - there are two areas one indicates 6 months one indicates 3 months.....any advice on how to manage all this would be so greatly appreciated!  D.

I am still going thru the Aetna POS Nightmare. I have been denied 3 times. My surgeon will be doing a peer to peer now & at this moment, thats my only hope of approval.  It's really a let down... I have been working on this whole WLS process for a year of my life...I had so much hope I could have a normal life again.  It took about 2 weeks for each denial. I had everything Aetna required, except they want you to have a 40 of higher BMI for the past 5 years. Mine dropped down to a 37 BMI 3 years ago. They also claimed I didnt do the 6 month thing, which I did, & the surgeon resummited thinking it was a mistake. It came back with, yes I did have that & there 1 reason to deny now was my BMI. I am not happy with Aetna, I have devoted the last year of my life to this. I pay Aetna alot of $$ a month & they have turned into a BIG dissappointment.  When it comes time to switch ins. companys I will not go thru them ever again.

Hi I have Aetna POS II (Philadelphia, PA).  My BMI is 52 and I have a couple of comobids (High Blood Pressure and Sleep Apnea). I was approved within 2 weeks (submitted on August 23rd - approved September 8th) When I went to the surgeons office I had 5 years of medical records. I had recently joined the gym at my job again so I provided my membership records. I also had a diet history record. The program was a multidisciplinary program so it took 3 months. I was first seen on June 28th, then July 26th then August 23rd. I would see the physcian or his assistant, the nurse to get weighed, the nutritionist (to speak about diet and exercise). I did all my lab work and saw a psychologist. During this time I was in constant communication with my PCP and with Aetna. I too was concerned that I would lose to much weight during the diet and would no longer qualify and I was told not to worry (essentially I weighed so much and would not lose enough in the 3 months).