Revision with Aetna Pos ii from Band to Rny

hi all! 

 

So so glad to talk to everyone. I had a band in back in 2008 and now I'm starting the process of revision to RNY.

 

does anyone have Aetna Pos ii and could tell be if they require 3 or 6 months of supervised diet before approval or is it seriously just one of the following criteria:

 

1. Conversion to a sleeve gastrectomy, RYGB or BPD/DS is considered medically necessary for members who have not had adequate success (defined as loss of more than 50 % of excess body weight) 2 years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
2. Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch, dilated gastrojejunal stoma, or dilation of the gastrojejunostomy anastomosis is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the dilation of the pouch or GJ anastomosis, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or 
3. Replacement of an adjustable band is considered medically necessary if there are complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments; or
4. Conversion from an adjustable band to a sleeve gastrectomy, RYGB or BPD/DS is considered medically necessary for members who have been compliant with a prescribed nutrition and exercise program following the band procedure, and there are complications that cannot be corrected with band manipulation, adjustments or replacement.

i would love any insight into your revision! Thanks!

Everyone's policy is different depending on your employer.   Your best bet is going to be calling the 800 number on your card and asking what your specific policy requires.   It could be that it won't be determined until you send in your file for approval.   Good luck! 

I have Aetna POS II and I have a lap band. They can be pretty strict on approvals. They denied me for a band removal even though it was surgeon recommended 4 years ago. Went back in recently due to severe reflux (and having had an unfilled band the last 4 years) and the surgeon's office said I had a slip and it HAD to come out. Aetna pretty much demands that it be medically necessary in order to cover. I did just get an approval yesterday for removal - I wish you luck!

Thank you! I go next week to my doc to see how to get the ball rolling. Not sure what I will need to show complience to nut and exercise after the band, but hopefully my reflux and bmi of 42 will help prove I need this revision. 

Hey...Im in the same boat. I have Aetna but currently going through 3 mo process. Would like to know outcome. Im converting from lap band to gastric bypass.