Aetna

 Who has it and what do they cover?

I have Aetna EPO.  They Cinical Policy bulletin states they covering the following:   Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures:

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) medically necessary when the selection criteria listed below are met. It requires you to have completed growth (18 yo), attempted weight loss in the past without long-term success,  and then it states you have to do a physician-supervised nutrition and exercise program or multidisciplinary surgical preparatory regimen.

  your not going to get a DS from Aetna, at least until *)(*) freezes ! i stand corrected the new policy bulitin of 9/8/2006 does provide a limited access to the DS, MY LAST DITCH APPEAL DATE IS 9/15,   MY SINCERE THANKS, I HAVE WORK TO DO.

I have Aetna PPO.  My policy pays a lifetime max of 10,000.  I had to provide 6 months cummulative diet and exercise history and 3 months consecutive diet and exercise history. I had detailed notes from my doctor. I also included a letter from me and a chart. I put their requirements in one column and in the second column, I referenced the page number ( in the faxed packet) that fulfilled the requirement. It took about 13 days to approve but I called daily and had my HR Generalist call on my behalf as well. Hope this helps.

I am currently going through the 6 months of doctor and dietician supervised diet.   I am going to get in touch with our EPA person and see if she can help me too.  I haven't sent the letter for approval yet, but hope to do all that in January. I am going to have the RNY done.

Aetna does not give a choice, except to have the rny, that is why I must do with out wls, as I can only have the DS due to physical restrictions from prior surgery to correct gerd.  If you have any second considerations about the rny, durring the fall open enrollment period i suggest shopping your choices carefully.  

Our HR rep (Gevity) was in our office today and she informed me that Aetna POS and Aetna Deluxe POS (at least for NJ I guess) are no longer covering this surgery. I contacted Aetna twice this past week and was told both times that they no longer cover any weight loss surgeries. I have been 100+ lbs overweight for at least 16 years. I have tried medication, weight loss groups and gyms. This was my last hope. I can't beleive I didn't do it last year when it was covered. I'm so depressed. Also, the best surgeons in Morris County at the best hospital (Morristown Memorial) in this county, no longer accept Aetna. Most likely because Aetna no longer covers the surgery  

They cover it, just not for your company,  I work for Verizon in NJ, and it is covered,   If your Union it may be still covered unless your union agreed to let the coverage be dropped this year.  There will be no health care changes for except for betterment for Verizon Union employees until the negiotiations of 2009.  

I had the DS on 11/15/04 and Aetna PPO denied me and later my company (ExxonMobil) denied the final appeal.  I haven't read all the data yet but is it possible to go through the appeal process again (what pain) requesting an overturn and reimbursement after their new policy effective 9/8/06 now recognizes the DS?  If so would I start with Aetna first or go straight to the company HR who made the final say? Thanks for any guidance.  I need help going after them again. Kris

Keep in mind that all plans and states vary.  Aetna covers more in some states and less in others.