Experiences with insurance (specifically Aetna)

Hi all! I was wondering if anyone can share their experience(s) with Aetna. I had my lap-band put in Nov 2006. I initially lost 30-40 lbs over a six month period (only my doing, the band certainly didn't help). I did get spuratic "restriction" after a couple of fills. It's either I can eat as much as I want with no problem, or I can't eat at all without horrible pain. I really want this band out, and to revise to a new surgery. I'm just very worried about whether or not Aetna will approve me. I used to work in the insurance industry (Anthem BCBS) and now I work at a laboratory and deal with UHC all day long. I've never had any dealings with Aetna in any great detail. I know how technical insurance can be. Here is the clause that I'm worried about:

1. 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;

Mainly, I am worried because I only followed up with my surgeon for 6 months following surgery...for a number of reasons. By that time I knew that this surgery was not working for me plus I lost my insurance. I was compliant with the prescribed nutrition and exercise program (or at least as much as possible since I didn't have help from the band), otherwise I wouldn't have lost any of the weight in those 6 months. I just hope that Aetna doesn't hold this against me.   Any experiences you have with insurance I would love to hear about.

Hey, PM me if you would like. Find a good PCP and surgeon and you will be fine.  I was approved immediately after showing medical necessity and I met that criteria. They gave me no problem at all about paying.

Thank you so much for your reply. I'm glad to hear they approved you with no problem. I'm just going to have to do what I need to do, and pray I have similar results!

I have Aetna and was approved for revision within a week. 

That Aetna policy bulletin suggests that the initial weight loss of the first two years from the date of surgery is significant, not how much time you spent with your physician. I don't think duration of your relationship with your surgeon is significant according to the policy. I am currently seeking a revision through Aetna. Though my issue is that the original surgeon has not yet submitted the request to Aetna. Good luck!

Thank you. Good luck to you as well

This posting is interesting.  I guess I got in front of myself a couple weeks ago when I called Aetna because all I asked is if they approve WLS and they said yes.  It didn't even occur to me to ask if they covered revisions.  Reading this makes my heart sink thinking there is a chance they may deny me.  My plan seems to be quite comprehensive overall, but...  like someone else said when companies are looking to reduce the premium costs, this might be an easy line item to strike off.

I will be making the dreaded call tomorrow morning to Aetna to find out about revisions for my plan.  I had my original WLS in 1998 and there are few records left from the surgery.  I just received copies last week and the only thing they still had was the surgery op reports, nothing on the sleep study or post-op visits.  Guess they will just be going off what I tell them.

I also have had a numer of side-effects from the surgery, but I just learned to adapt I guess- am not one to run to the Dr. office really.  Things like food getting stuck, sometimes leading to vomiting, bad gas at times, and of course never reaching my goal weight- but did loose some weight.

Here's hoping to good news tomorrow morning....

In the medical policy for WLS, Aetna does say they pay for revisions, but specifically ask if you have a one wls per lifetime exception on your plan. I checked mine for that last week, and thankfully they didn't. I hope yours will get approved : ) I have Aetna through Quest Daignostics (my employer).
I've been so busy trying to figure out which surgery I want that I've not been too stressed thinking about if they'll approve me. lol.
Which surgery are you going to revise to? I assume you had VBG before (b/c of your name).

I'm in Ohio and have Aetna Open Access as a state employee. I had RNY in 2003. I stopped losing completely after 6 months. I'm currently only 40 lbs lighter than my original pre-op weight, but my BMI is 39.5. I also have problems with ulcers, sutures coming out and bleeding on the staple line. I'm trying to get a revision to DS with Dr. K. Aetna denied me because although I have the sutures/bleeding, pain, vomiting, etc ... my pouch is normal size and so is the stoma. I just submitted my appeal. I did an expedited appeal based on the level of pain that is being caused by the delay. They are supposed to reply within 72 hours -- so that would be Thursday. I'm not holding my breath. Without the revision, I have no idea what other option there is for me, since my surgeon at OSU will not do anything other than continue to do EGDs and try to cut out the sutures and ulcers. WTF!!!!