So Confused, Aetna in Virgina

 I am driving myself nuts trying to figure out if I am going to qualify. I called my insurance company (Aetna) and was told yes, my policy does cover banding, but the only other thing she would tell me is to read the Clinical Policy on the website--she wouldn't answer any questions. My drs office says "turn in all your paperwork and we will let you know". Well getting it all together is a pain just to have one simple question lead to a no. And I have to gain 5 pounds to meet a 40 BMI which I am working on! I will be pissed if I gained 5 more pounds and then am turned down.

Here is the confusion:

The Aetna Clinical Policy says: (bolding mine)

 Selection criteria:

1. Presence of severe obesity that has persisted for at least the last 2 years, defined as any of the following:
2. 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 or
      4. Medically refractory hypertension

 

So I have not met the criteria for the last 2 years. BMI will only reach 40 by next week (hopefully), and I have none of the listed medical conditions to qualify with my lower BMI the last 2 years.

BUT! And this is the big but. I read that in VA the Insurance codes require that the criteria to qualify only have to meet the NIH guidelines. So I searched out that State Code: (again, bolding mine)

 § 38.2-3418.13. Coverage for the treatment of morbid obesity.

B. . . . Standards and criteria, including those related to diet, used by insurers to approve or restrict access to surgery for morbid obesity shall be based upon current clinical guidelines recognized by the National Institutes of Health.

 

And I have found and read the entire 94 page PDF from the NIH "The Practical Guide Identification, Evaluation and Treatment of Overweight and Obesity in Adults" which is the clinical guidelines for doctors. No where in there is there a stipulation that the qualifying condition has to have been present for 2 years prior to surgery. Just that the BMI needs to be 40 or greater.

So all I want to know is do I have to have met the 40 BMI criteria for the last 2 years or not? Is this a State Code that supercedes the insurance requirement?

 

All of this is so confusing. Anyone understand this???

Thanks!

Is your employer based out of VA? I ask because just because your office is in VA does not mean you necessarily work for a VA corporation. The state laws that apply to your particular insurance policy are the laws of the state in which your employing company is incorporated. I live in VA, but I have my husband's insurance, and his company is based in MD.

I also have Aetna, and I did have to have the 2 year history of morbid obesity. I've not heard of this VA state law before - I wish you luck in figuring it out! I would think your surgeon's office's insurance coordinator would be your best resource. Or, you may even want to post this on the VA State board here on OH.

Aaaa!  That makes it even more confusing then!  The main office  (DH's work) is apparently in WA state.

But the first part of the VA statue says: 

The provisions of this section shall apply to any such policy, contract or plan delivered, issued for delivery, or renewed in this Commonwealth on and after July 1, 2000.



Does that make the plan "delivereed" in the state of VA?  I don't know how anyone figures this stuff out!

Have u had any updates. My understanding with Aetna was that it had to be 2 yrs of <40 BMI.