Aetna PPO, questions

Wow, this message board is full of information.  I wonder if any of you can help me with some questions I stil am stewing over: Background:  I have Aetna PPO policy that does provide for obesity surgery for morbidly obese according to SPD this means at least 100 pounds overweight.  When I called my plan administrator (Aetna for Dow Chemical), I was told this was a covered benefit if I met the selection criteria of Aetna Clinical Policy bulletin 0157.  That CPB states must have been severely obese for 5 years; and BMI of over 40 or BMI of 35 with one of following co-morbidity : Type II Diabiabitis, Cornary Heart Disease, Severe Sleep apnea or hypertension not controlled by medicine. I have a BMI of 36, with CHD, severe apnea and hypertension not controlled by medicine.  I have letter from specialists and my PCP outlining these co-morbidies with letters of medical necessity.  I am currently in month 2 of Multi-discipline program prior to surgery (they require a three month program).  My surgeon plans to submit to Aetna after I complete the 3 month Multi-discipline program.  I want to get approval for Lap Band surgery. My questions: 1.  Do I have to have a BMI over 35 for past 5 years with these severe co-morbidities?  My lowest BMI in past 5 years was 31.  My family has history of heart disease, and my sister had heart attack and triple bypass at age 52.  I also have coronary heart disease, but no heart attack yet.  I am now 52 years old. 2.  Am I wasting my time on this approach?  I am not 100 pounds overweight. 3.  The Three month multi-discipline program is being paid out of my pocket and I am afraid that I am wasting my money. 4.  I am nervous about having surgery without insurance payment because if complications arise, my insurance will not cover any complications. Any experts out there with some insight? Thanks in Advance.

Thanks for this information Paul.  I called today to ask them to bill using metabolic syndrome, which is exactly was my cardiologist has shown as one of my co-morbidities.

I found your information on the pre-cert diet good to know too.  Congratulations on your smooth surgery. 

Aetna PPO Questions:  1. I have Aetna PPO and I too had the same qualifications. I supplied to my surgeons office a copy of the sheet from my PCP that shows my weight for the past five years (ranging from 200 - 250) I have no co-morbidities per se - My blood pressure is high sometimes. I joined YMCA about 8 months ago and submitted the receipts to my surgeon. My surgeon sent my receipts, letters from Psyc, Nurtitist and PCP sheets to Aetna. It took two weeks to get an approval.  2. Don't give up. Get the info you must submit to the insurance company and go from there. One day at a time.  3.  Multi-discipline program is good for anyone. Excerise after you have surgery is necessary. What a great way to start before hand.  Hope this helps.  From Virginia - USA

Thanks for the reply.  Yes, I appreciate your comments.  You have encouraged me to keep at this and try for approval.  I will definitely gather all the documentation I can.

I have Aenta Pos 11  as well.  My bmi weights  for the past 4  years   have  been  between 36-38.  The  5th year  would be  bmi  41.  My Co mor. are high blood pressure  (med)  shortness of  breathe  low   back pain.

Weights  2002 210                  2003  220                   2004  221                  2005   219                  2006   242 I wondering will  I have problems  with getting approved? Any experts out there with some insight? Georgejet  New  here