Will Aetna cover a gastric bypass revision?

I had roux en y gastric bypass in 2001 when i weighed 375.  I lost about 100lbs. but have gained some of that weight back.  I DON'T DUMP YOU GUYS!!!  I can eat ANYTHING I want with no dumping (which is what my problem is!)

Any thoughts?  Please help
J

Aetna approved my faux (common channel left too long) DS to a real DS revision very quickly. This is just my experience. Hopefully you will have a positive outcome as well.

Angie

Though I do have a Rny in me now, it backfired. I have gained weight back. Not only that, I have learned that dumping is one of the worst things to do to yourself. Get the DS and you will not dump again, but still lose all your weight and be able to keep it off a lot easier. I am going for the Ds. God willilng, I will get it one of these days.

They covered mine in May of this year!  you can check out criteria on their website, I got denied 1st time around, sent in appeal and approved 8 hrs after my first call to underwriter.

would you mind elaborating on what you wrote in your appeal.  I saw a doctor a couple of weeks ago and they called the insurance company and they said it wasnt covered.  but I have atena ppo. she gave me the info for me to call the insurance company but I havent been able to yet. Its like they didnt even try... I remember how hard i had to fight the first time around but wanted a bit more info on what i should put in my revision appeal letter.

 Wow that  sweetie Nurse4lyph. posted  the info !!! 
 
  BUT U need to call and get a copy for your records. Ask the questions. ask the procedure to follow. Your Dr office may be too busy or not asking the correct questions.

In your letter  be will to send  copies of your weight  gain ,  and any issues your having .  make yourself a   Real person in your letter - express your feelings .   

Guess I was Lucky and fell under the #4 criteria - but I did not have the d.s. conversion - I am simply a extended rny'er  - meaning my common channel was shortened.

Best of luck - it's aggrivating process at times . just dont give up !!



 Post Date: 1/5/09 7:53 pm
I happen to be an Appeal Nurse Analyst for Aetna and am attempting to go through this process myself right now. Same scenerio as above I had RNY in 2001 and in 2005 began gaining weight and now I am up 90 + pounds.

Aetna's Clinical Policy Bulletin (CPB) # 157 Obesity Surgery: 

1. Repeat Bariatric Surgery:
2. Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction or stricture.
3. Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:
4. Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or

5. Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure.
   
   GOOD LUCK !!!!
   
    

Thanx for the info ladies!

One more question....What are some of the things that Aetna looks for in determining your approval for revision surgery? Thanks again

Go online and look at the criteria !!! it's there

I happen to be an Appeal Nurse Analyst for Aetna and am attempting to go through this process myself right now. Same scenerio as above I had RNY in 2001 and in 2005 began gaining weight and now I am up 90 + pounds.

Aetna's Clinical Policy Bulletin (CPB) # 157 Obesity Surgery: 

1. Repeat Bariatric Surgery:
2. Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction or stricture.
3. Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:
4. Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or

5. Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure.
   
   GOOD LUCK !!!!

I'm currently looking to go thru bypass in NYC.  I found a surgeon.  I'm going thru the 6 months of dr supervised diet.  I have a few questiions.

What if the supervised weight loss is significant and aetna says, well you ovbviously can do it on your own?  does that happen?

Im currently 326 lbs down 14 lbs from my 1st month of dr supervised.

um, should i contact aetna and see if I will get approved now or just wait until the dr's office does it?

I looked at the clinical bulletin so I hope that Im doing everything okay.

also - will they want my medical records and how far back?  Ive been going to the same PCP dr for over 15 years.

Thanks!