AETNA and approval??

Hi, I'm K and although I am not new to WLS I am new to this new insurance I have now with Aetna. I spent over 4 hours on the phone today trying to get some clarification on the steps to get approved, and it came down to a big circle... no one could help me.  I know exactly what I need to qualify, but I have specific questions in regards to some of the fine print. I started this journey almost 10 years ago. I was banded in 2006 and lost almost 90 pounds. I had Anthem BCBS PPO and had no problems getting approved.... In 2009 I had my band removed because it had slipped and I had become very sick, malnourished, dehydrated, pretty much on deaths door. The Dr offered to revise and fix it for me but I opted to have it removed because I had switched jobs and no longer had Bariatric coverage...fast forward to last year April 2013 and I made the decision to try WLS again-- this time with the Sleeve. I now have a new job now and I called Aetna and found out the details for the coverage, however, up until today some of the qualifiers were NEVER disclosed to me. I had my consult with my Surgeon today as well as the Dietician... had some blood work done and he says I am an excellent candidate for the Sleeve!! YAY!!!! I thought to myself I am almost there.....couldn't be more wrong....  I know MANY of you have walked down this path as I am going on now. I am looking for advise and support as I go down this road again. 

I have Type II Diabetes, I have BMI 45.3, previous WLS and on my second round of Phentermine. I started my "6 month physcian supervised" office visits in April 2013, I went every month- April, May, June, July,September, November, January '14, February '14....Now I find out I have to have an excercise program, nutritional consults= all Dr supervised... Where do you go that a Dr supervises your workouts? I can bare,y afford my monthly co pays let alone all these other hoops.  I am so disappointed and trying not to get discouraged but I cannot get any clear answers from my insurance company and I am so scared I am going to be set back another 6 months or more???

I have Aetna and they're VERY specific!!! My WLS surgeon did the whole program pre-op whi*****luded exercise and dietitian. I tell everyone to do their pre-op program through their surgeon, as they work daily with various insurances and know EXACTLY what needs to be done to qualify. Although you dud one through your PCP, it may not include everything needed to qualify. 

Here is Aetnas clinical guidelines for WLS. However, some of this can vary from plan to plan. http://www.aetna.com/cpb/medical/data/100_199/0157.html

Good luck!!! Insurance isn't always fun to deal with but if you want their help you have to play by their rules...

Thank you... This was the page/info I found that I spent nearly 4 hours on the phone tonight with Aetna and got absolutely no where. My surgeon does not have a program that includes exercise, just a dietician, and a nutrionist for pre-op/post-op diet.....  I don't have a lot of in-network surgeons in my area, so I chose this DR based on feedback and recommended by my PCP. I met him today and he is awesome... I just hope his insurance coordinator is too.

So you think I am looking at another 6 months ahead of me? 

Unfortunately, you probably will. I only say this because I was in a similar situation. I had began a physician supervised program but it was not sufficient enough to qualify for WLS. I had to start again. There is VERY specific criteria that MUST be charted each month and until you KNOW what that criteria is, it's probably not all been done. For example, the exercise part of the program was me meeting with an exercise physiologist and she did an assessment of what I could currently do. Then she put together a customized program and charted my progression each month (ie was I able to increase amt or time of physical activity, etc). The NUT I met with went over VERY specific things like EXACT protein grams needed both pre and post op. I know this sounds crazy but it's all meant to educate you to be more successful post-op. While overall I cannot complain about Aetna, as they paid 100% of my surgery! I did have to follow their rules to the letter regardless how many hoops I had to jump through. 

I know this feels like a set-back but remember this is all to help you succeed long-term. At the end of the day, the program is 6 months, while the surgery us modification of your life for the rest of your life. Good luck!!! I'm sure if you do everything they want you'll have no trouble getting approved.

Oh, BTW - if your PCP didn't chart any specific excercise / nutrition recommendations with progress you probably will have to repeat the program to qualify. Although, this may be included in your surgeons fee if you do it through them. Mine did. ALSO, my BMI was right at 40 with no co-morbidities and I was told NOT to lose any weight during my program. At my final weigh-in just before submitting to insurance, I weighted 4 lbs heavy. Aetna DENIED me initially based on my FOUR POUND gain. I took two weeks and got it off so the decision was reversed. Just a word of caution... If you gain even 1-2 lbs they WILL deny you!!! This has become common practice with them according to my surgeons insurance coordinator!!! It's okay to weight exactly the same or lose. In my case it was primarily the difference between starting my program in the summer and weighing in wearing a sundress versus in December in sweater, jeans and boots.

I also have Aetna, and they spell it out in writing pretty clearly. My surgeons office found it for me and sent me a PDF of the agreement. It clearly states that I cannot gain ANY weight during the doctor supervised diet and exercise plan.  My surgeons office also gave me copies of exactly what the insurance co is looking for in the chart notes. I gave that to my doc. Now I'm worried, because he isn't telling me what to eat, but I tell him of what I'm doing. Hope it turns out for you. Maybe you could recruit your surgeons office to advocate for you. Good luck!

Thank you.. I had the Insurance profile up when I was on the phone with AETNA  for 4 hours tonight. I just needed some clarification and no one could give it to me.  I know my PCP and I discussed my weight at each visit along with my exercise and eating habits. But she never gave me a program to follow bc she felt I was doing all I could do.... She did put me on Phentermine to help, but she does not get a report or an email every time I go to the gym or walk around the block....that is what I need to clarify... plus the dr supervised nutrition program? I never saw a Nutrionist... Oh I feel an up hill battle calling and I am already feeling blue....