Aetna and my BMI

Here is what I did (and what I suggest):

Start your 6-month diet with your doctor now--ASAP. That is the biggest pain. Aetna will also accept a 3-month multidisciplinary program, but this is difficult to do on your own without something like a surgeon's office's established program for this (which you would likely have to pay out-of-pocket for). Take that 6 months to research the heck out of WLS so you know EXACTLY which procedure you want (many don't know there are more options than just the band or gastric bypass).

Start researching surgeons in your area who perform the surgery you want. Attend more than one surgeon's information session (most have free ones a couple times a month). Check to see which surgeons are in-network for you, and have your PCP write you a referral so you can set up a consultation.

The surgeon's office, not your PCP's office, will likely handle everything insurance-related. That's how it worked for me. Most WLS offices have a person whose sole job it is is to work with insurance. I would even go so far as to say most WLS insurance coordinators will be familiar with Aetna, so that would also be a good resource for information.

Do you have daytime sleepiness? Do you drift off easily and always feel tired? If so those symptoms along with snoring could indicate sleep apnea. At your next appointment tell her if you have the above symptoms. If she still won't refer you call up your insurance company and tell them that you've asked her on numerous occasions to refer you for a sleep study and she has yet to do so. I think you would file a grievance on not getting the referral. Let them know about the symptoms you are having. 
And like Jill said if your PCP isn't cooperative get a new one. You need to be your own advocate and demand the care you deserve. Sleep apnea is a very serious comord that can make your health worse: high blood pressure, stroke and it can actually cause you to gain weight because your body isn't getting enough rest. 

I am sleepy all the time it seems. I just thought it was my being overweight or a little depressed. I never really gave any thought to sleep apnea. I think if I asked her to go to a sleep study she would refer me. Sometimes ( most times )  it just feels like I have no energy. I have to force myself to really do ANYTHING.

PCOS is not considered a co-morb with Aetna. Their clinical policy bulletin ( http://www.aetna.com/cpb/medical/data/100_199/0157.html )defines their selection criteria as:

Presence of severe obesity that has persisted for at least the last 2 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);
      
      Do you know how far back you reached a BMI of 40?
       

I just got approved by Aetna...Its a pain!  honestly, i dont think you should "word" it any way to them, its their job to look over your medical records.  if I were you....i would just send in 2-5 years of weight history and any comorbids that you have now.  make sure to follow the rest to a t but b/c their cbp isnt that specific in that reigon....it cant hurt to try....your dr should let you know when they send a list to aetna...and then before they submit...they tell you what you may be missing...well thats what my drs office did anyway.

 

God Bless!

I have Aetna too. If you'd like, I can send you a breakdown of what all I had to do and copies of the letters that were submitted. I did the three month regimen and was responsible for getting everything in order myself. Anyway, if you are interested, just leave me your email addy and I'll get it out to you. :)