Aetna approval question.

I have Aetna, and I hear they can be real bears about approving WLS.  I have been seeing the same family doctor since 2006, but never got weighed at his office because his scale only goes up to 350 and I weigh more than that.  When I went to talk to him about the surgery, he wrote me a letter for the surgeon's office to submit.  It basically shows all of my records, the fact that at each visit we talked about weight loss, nutrition, etc., states that I didn't get weighed because his scale didn't go high enough, and that without this surgery my life is in danger.  With all of this and 3 months with the nutritionist, the fact that I am diabetic and have high blood pressure, and gall stones, what do you think my chances are of being approved the first time?  Thanks in advance!

Hi,

I hope I can be of some help.  I have Aetna POS and was approved for and had my surgery last year.  My daughter just got approved and is having surgery May 10th and she is also covered under my Aetna insurance.  BOTH of us were denied at first, but we appealed and both times the decision was overturned and we were both approved (the 2nd time aroundl).

My first suggestion would be to get a copy of their clinical policy bulletin 0157 which spells out the requirements for WLS to be covered.  Use this as your checklist to make sure you are meeting all of their requirements.    One of the requirements is having to do either a 6 month physician supervised diet or a 3 month multidisciplinary program.  My daughter and I both did the 3 month MD program.  But you have to have one or the other or you will get denied. 

If I'm reading your post corredtly, you have been to the doctor since 2006, but do you have a physician supervised diet where you went in consecutively for 6 months in a row.  They are looking for documentation - meaning your physicians office visit notes, where you went 6 consecutive months in a row and documented being there for wieght loss, and discussing such things as a reduced calorie diet and exercise.  If you haven't done that, that is where you need to start.  They also require proof of obesity that has consisted for more than 2 years.  Once again, that would be anything that would show proof of your weight for at least 2 years, with obesity being defined as a BMI of >40 and no co-morbidies or >35 with 2 co-morbidies.

I hope this helps a little.  Let me know if you have questions! 

Nan