Aetna Insurance question

 
I am asking this in regards to my daughter, not myself as I had surgery a year ago and was approved through Aetna.  I have Aetna PPO and my policy does cover WLS.  When I went for my approval, I had the required 2 years of weight history where my BMI never dropped below 40.  Their requirement is 35+ with 2 co-morbidies or >40 and no co-morbidies. 

My daughter is covered under my insurance and she has completed the same process I did for her approval so I am sure she has met all the requiremnts since it is identical to what I did.  We will be submitting her paperwork for approval tomorrow!  She does have a 4 year history where her BMI is over 40 with recorded weights in 2007, 2008, 2009 and 2010 of BMI >40. 

The difference between hers and my situation is, she also has weights in those years where her weight dropped below a 40 BMI.  This was when she was dieting and 'attempting to lose weight' because Aetna also requires proof of attempted and failed weight loss.

My question is does it matter that her weight dropped for a few months during those years as long as she has recorded weights of BMI over 40 in each year documented with our physician?

Thanks for any insight anyone may have.

Nan

Hi Nan,
Would it be possible to have the  PCP  take the paperwork where her BMI was not 40 out of the records you send to insurance?  I wouldn't take a chance I really hope she get her approval. 

HI Wendy,

That is a great idea that I hadn't thought of.  She has documented weights from 2007, 2008, 2009 and 2010 with a BMI or 40+.  But also in the same years she has them below 40 due to her dieting and trying to lose weight.  So it's a catch 22 because they want you to show 'attempted weight loss' but in the same breath they require a certain BMI.  I just don't know if it means a constant BMI or as long as there is one from every year over 40 it's okay.  But you are right, those PCP notes could just not be submitted and she would show 4 years of a BMI over 40. 

THanks for the reply!

Nan

 

That's the approach my surgeon's office takes -----they only submit what is necessary to meet the requirements and leave out the rest.

You are right - -- it is a "catch 22".