Question:
I am a bunch of nerves...reagarding approval with Aetna HMO

I have Aetna HMO. My husband works for a small company no more than 500 employees. Out of that I think 80 of them or less use the plan. I have already called aetna and they said it is covered as long as it is medically necessary. We pay 147 every two weeks plus the company contributes 70 dollars a month. Is this a self funded plan? My papers get submitted next week and if I am denied I will just die. We never received a list of exclusions from the company. I hate being in the unknown. Thanks Dana    — Dana N. (posted on April 25, 2001)

April 25, 2001
If Aetna said that it is covered as long as it is medically necessary then they can't have it as an exclusion. It does not sound like it is a self-funded plan. I have included below an excerpt someone else included from Aetna's website (www.aetnaushc.com) Aetna Approved after appeal letter (08/06/00) Laparoscopic RNY Weeks to approval : 4 Pre-Op BMI : 50.8 Comorbidities : sleep apnea, gastric reflux Policy : Must be medically necessary Comments : The Aetna policy on the surgery is posted on their web site. I did not initially provide documentation of medically supervised weight loss. Once I did the surgery was approved. ***** Aetna Policy: Subject: Obesity: Surgical Treatment Aetna U.S. Healthcare covers the surgical treatment of obesity when the following criteria are met: (These criteria were adapted from the NIH Consensus Conference on Surgical Treatment of Morbid Obesity.) 1.Presence of morbid obesity, defined as a body mass index (BMI)* exceeding 40 or greater than 35 in conjunction with severe co-morbidities such as cardiopulmonary complications or severe diabetes; AND 2.documented history of repeated failure of physician-supervised medical/dietary therapies. ***** *BMI is calculated by dividing a patient's weight (in kilograms) by height (in meters) squared. To convert pounds to kilograms, multiply pounds by 0.45 To convert inches to meters, multiply inches by .0254 Candidates for revision of gastric restrictive surgery must have a complication of the original procedure, such as obstruction or stricture. In addition, revision of gastric restrictive or bypass surgery, which has failed due to dilation of the gastric pouch, is appropriate if the original procedure resulted in weight loss prior to the pouch dilation. Aetna U.S. Healthcare does not cover ANY of the following procedures because the peer reviewed medical literature shows them to be either unsafe or inadequately studied: Loop gastric bypass; Gastroplasty using staples to create a small pouch; Duodenal switch operation; Biliopancreatic bypass Laparoscopic adjustable silicone gastric banding using the LAP-BAND Note: As a high incidence of gallbladder disease (28%) has been documented after surgery for morbid obesity, Aetna U.S. Healthcare covers routine cholecystectomy in concert with elective bariatric procedures. Background: Accepted surgery for morbid obesity, termed bariatric surgery, includes gastric restrictive procedures and gastric bypass. The gastric restrictive procedures include vertical banded gastroplasty and gastric banding which attempt to induce weight loss by creating an intake-limiting gastric pouch by segmenting the stomach along its vertical axis. The process of digestion is more or less normal. Gastric bypass combines gastric segmentation along its horizontal or vertical axis with a Roux-en-Y procedure, such that the food bypasses the duodenum and proximal small bowel. Because the normal flow of food is disrupted, there are more metabolic complications compared to gastric restrictive surgeries, including iron deficiency anemia, vitamin B-12 deficiency and hypocalcemia, all of which can be corrected by oral supplementation. Several studies have suggested that gastric bypass is a more effective weight loss procedure than vertical banded gastroplasty, offering the best combination of maximum weight control, and minimum nutritional risk. While appropriate surgical procedures for morbid obesity primarily produce weight loss by restricting intake, intestinal bypass procedures produce weight loss by inducing a malabsorptive effect. Biliopancreatic bypass (also called jejunoileal bypass or the Scopinaro procedure) consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure; the result is a 200 cm long alimentary tract, a 300 to 400 cm biliary tract, and after these two tracts are joined at the distal anastomosis, there is only a 50 cm common absorptive alimentary tract. It was designed to address some of the drawbacks of the original intestinal bypass procedures which resulted in unacceptable metabolic complications of diarrhea, hyperoxaluria, nephrolithiasis, cholelithiasis and liver failure. Although this procedure is reported to have a higher rate of weight loss, it is rarely performed in the United States due to the high risk of various metabolic complications. Gastroplasty, not to be confused with vertical banded gastroplasty, is a technically simple operation, accomplished by stapling the upper stomach to create a small pouch into which food flows after it is swallowed. The outlet of this pouch is restricted by a band of synthetic mesh, which slows its emptying, so that the person having it feels full after only a few bites of food. Patients who have this procedure seldom experience any satisfaction from eating, and tend to seek ways to get around the operation by eating more. This causes vomiting, which can tear out the staple line and destroy the operation. Overall, about 40% of persons who have this operation never achieve loss of more than half of their excess body weight. In the long-term, five or more years after surgery, only about 30% of patients have maintained a successful weight loss. Many patients must undergo another, revisional operation, to obtain the results they seek. Although the basic concept of gastric bypass remains intact, numerous variations are being performed at this time. Recent data demonstrate that surgeons are moving from simple gastroplasty procedures, favoring the more complex gastric bypass procedures as the surgical treatment of choice for the morbidly obese patient. The gastric bypass operation can be modified, to alter absorption of food, by moving the Roux-en-Y-connection distally down the jejunum, effectively shortening the bowel available for absorption of food. The weight loss effect is then a combination of the very small stomach, which limits intake of food, with malabsorption of the nutrients which are eaten, reducing caloric intake even further. In a sense, this procedure combines the least-desirable features of the gastric bypass with the most troublesome aspects of the biliopancreatic diversion. Although patients can have increased frequency of bowel movements, increased fat in their stools, and impaired absorption of vitamins, recent studies have reported good results. The loop gastric bypass developed years ago has generally been abandoned by most bariatric surgeons as unsafe. Although easier to perform than the Roux en-Y, it creates a severe hazard in the event of any leakage after surgery, and seriously increases the risk of ulcer formation, and irritation of the stomach pouch by bile. Recent advances in laparoscopy have renewed the interest in gastric banding techniques for the control of severe obesity. Recently, laparoscopic adjustable silicone gastric banding (LASGB) using the adjustable LAP- BAND has become an attractive method because it is minimally invasive and allows modulation of weight loss. Their advantage is the adjustability of the band, which can be inflated or deflated percutaneously according to weight loss without altering the anatomy of the stomach. This method entails encircling the upper part of the stomach using bands made of synthetic materials, creating a small upper pouch that empties into the lower stomach through a narrow, non-stretchable stoma. The reduced capacity of the pouch and the restriction caused by the band diminish caloric intake, depending on important technical details, thus producing weight loss comparable to vertical gastroplasties, without the possibility of staple-line disruption and lesser incidence of infectious complications. However, distension of the pouch, slippage of the band and entrapment of the foreign material by the stomach have been described and are worrisome. The FDA has not yet approved this device and procedure for use in the United States, and so it still is considered investigational. Please check their web site at http://www.aetnaushc.com/cpb/data/CPBA0157.htm to get the latest information and references for this policy. Source: [email protected]
   — Mary H.

April 25, 2001
Hi, I have Aetna HMO....and work for a small company also...According to my surgeon's office, Aetna is one of the easier insurance companies to deal with....I have a high BMI 51 - The MA from my surgeon's office called Aetna, and received an approval over the phone...and I received my approval letter from Aetna three days later...now I know it is not always this easy...but after reading the insurance posts for my state (Ohio) it sounds like they are fairly good to work with!! Good Luck, Karan
   — chance2lv

April 25, 2001
I have Aetna, they approved me on the phone with the doctor in two days, A week later I got a letter of approvel. My doctor said Aetna was one of the best,,,,,Plus uou don't have to go for all those extra tests, with the other insurance companys. make you go through.
   — Marie B.

April 25, 2001
My husband works for a small company that uses Aetna HMO and I was approved in TWO DAYS!
   — PT LawMom

April 25, 2001
Don't worry! Aetna is the best when it comes to approving WLS. I was approved in 24 hrs & got the approval letter a week later. As long as you qualify.. BMI of 40 OR 35 W/ Comorbs.. you'll be fine! Godbless!
   — sgeisendorff

April 25, 2001
I also have Aetna HMO. I was approved within 2 weeks. My sister-in-law had no problems getting approved with them either. Best of luck to you.
   — Pamela B.