Definity Health vs. Aetna PPO

Hi, We currently have Aetna PPO. I have already received my first denial for RNY. They said I didn't document my weight for 5 years, even though I included medical records going back to 1999 whi*****luded my weight. They also did not accept the diabetes diet and exercise program I have been following for the past 2+ years, even though it was supervised and I have been very successfull with it. In the mean time, I have decided that I want DS instead of RNY. I know this will make things even harder with Aetna. When open enrollment comes around we could switch to Definity Health. Bariatric surgery is supposed to be a covered benifit for both plans. The HR person tells me all I need is for my Dr. to say it is medically neccesary but she also says they will do whatever Aetna tells them to. Both plans are self-funded. Any advice or experience you can share would be very welcome! Thanks, Laura

Hi Laura. I went to hell and back with Aetna. Aetna is difficult to deal with. I had to appeal my case and I sent them a detailed appeals letter outlining their requirements and including each supporting document into the letter. My letter (package) was about 20+ pages and I sent it certified. What I would do is call and speak with a specific person, get their name and address and send it to them. Ask for their specific number and bug the hell out of them until you hear something. That's what I had to do. Don't mail the appeals letter to the address for appeals because it will get lost and you will never hear anything. That's what happened here. I had to send this whole mess out again for the second time. I called everyday until I got an answer.

Aetna isn't always horrific - they just want things thoroughly documented. I did a well-documented 6-month diet with my PCP and was approved quickly. My records only went back four years, but really the only thing they seemed to care about was the documented diet (with monthly weigh-ins and details/updates about the exact diet and exercise program followed) However... if you want the DS, you'd better look into Definity. Aetna will, under certain cir****tances, cover the lap-band or VGB (they recently revised their policy in this regard). However, they still consider the DS too experimental. I think some people have fought Aetna successfully on this (ask about it over in the DS forum), but it won't be easy.