Question:
Did Aetna change their criteria for the 6-month diet on 8/22/03?
I went to my PCP today to broach the surgery subject and to get started on my 6-month diet. (He was supportive..yay!) I went to the Aetna site and printed out the coverage criteria to take with me. I noticed that it was dated 8/22/03 at the bottom. I read through it and the 6-month diet requirements look different than I remember from the last time I read them, a few weeks ago. The requirements specifically said the monitoring physician could not perform bariatric surgery, and that you could apply for precertification before the end of the diet provided the full 6 months would pass before the surgery date. Could someone who's familiar with the Aetna coverage comment on whether this is a change? Here is the address: http://www.aetna.com/cpb/data/CPBA0157.html — cabingirl (posted on August 27, 2003)
August 27, 2003
Hi, I have Aetna and had printed this info out a few months ago. I can't
find my copy, but I saw a couple of things that I know are different than
when I fought my battles.
1. They can require a psych evaluation - this wasn't on there 3 months
ago.
2. Before, they allowed both RNY or VGB, now they will only authorize VGB
under certain conditions.
As for the monitoring physician not being a bariatric surgeon...that was in
effect on the Jan. 2003 bulletin. They have added though that you can
apply for approval prior to completion of the 6 month supervised diet which
in my opinion is a big plus. I couldn't be approved until the end of my 6
month diet.
Feel free to e-mail me directly if you'd like. I thought AETNA was
relatively easy to deal with and I did most of it myself as I got tired of
waiting on the surgeons office.
— Carolyn M.
August 27, 2003
I agree with the previous poster. I have been monitoring Aetna's #157 for
some time, and it DID change, just as she said.
I fought Aetna for 6 months to get the DS approved; however, I was approved
immediately for the RNY (which I specifically said I didn't want, but that
if they would not approve the DS, they should, at the very least, approve
the RNY -- that way, when I appealed it was only WHICH procedure that was
the subject of appeal, not whether I was qualified for surgery). The way I
drafted my letter was to list each of the requirements in CPB #157 as a
section heading, and then list (with reference to appended copies of pages
of my medical records) exactly how I met the requirement. It made it
easier for them to approve me -- at least for the RNY. Diana
— [Deactivated Member]
August 27, 2003
I've seen a lot of complaining about Aetna's requirement for the past 8
months. I think that you can be approved before the 6 months is up is a
huge improvement. Since sometimes it can take a few months after approval
to actually have surgery this really cuts down the total time. I do not
like to hear that they will only approve the VGB as that is a very
shortsighted decision in my opinion. But the 2nd poster said she got RNY
approval no problem. If anything I would think they would go RNY instead
of VGB if they will only cover 1.
— zoedogcbr
August 27, 2003
Chris - I think you misread the first respondent's statement. I believe
that she meant that they approve RNY routinely but they will only authorize
VBG under special circumstances. In fact, they are authorizing more than
they would before because it looks like they now will cover the Lap-Band in
special instances:
<p>
<i>Aetna considers open or laparoscopic vertical banded gastroplasty
or laparoscopic adjustable silicone gastric banding (LASGB, Lap-Band)
medically necessary for members who meet the selection criteria listed
below and who are at increased risk of adverse consequences of a Roux-en-Y
gastric bypass due to the presence of any of the following comorbid medical
conditions:
<p>
Hepatic cirrhosis with elevated liver function tests; or
Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or
<br>
Radiation enteritis; or <br>
Demonstrated complications from extensive adhesions involving the
intestines from prior major abdominal surgery, multiple minor surgeries, or
major trauma. <br></i>
JR
— John Rushton
August 27, 2003
"The requirements specifically said the monitoring physician could not
perform bariatric surgery" Hi there I'm am 3 months post-op and I had
Aetna and they had that same wording but I think they have changed it a
little bit. At first I was denied because they didn't have the records from
my PCP's office of my 6 months supervised diet. So, they sent them over
then I was approved for the DS! They didn't even fight me on which
surgery. Thank goodness for my doc's office! Good luck!
— Cinda R.
August 27, 2003
I agree with JR on this is better than is was. It is a giant step for
Aetna. I am 4 months post op and have Aetna. They would not cover the lap
band when I went for my approval nor could you get approved prior to the
completion of your 6 month diet. Aetna is not hard to deal with I was
completely approved in three weeks. It has cost me less than $500.00 for
the complete surgery. I an very happy with them. Good Luck!
— Barbara S.
August 28, 2003
This ddiet history requirement is something the insurance companies have
started using to determine if you meet the medical necessity criteria.
However, medical necessity is subjective and better determined by your
examining and treating doctor. Most policies right now do not have this
requirement in them.
In fact, yesterday my firm was able to get another appeal granted for
someone who was denied based on a diet history. Don't let up on these
companies, keep fighting.
— gary viscio
August 28, 2003
No this specific change you are talking about is not new. It was in my
requirements in 5/03 when I submitted my paperwork for approval. They did
require the consulting or monitoring doctor to be separate from the
bariatric surgeon. I think they just want to make sure you are getting
objective opinions (one from pcp, one from surgeon).
— doubleh
August 28, 2003
Thanks for your answers, everyone. I didn't have an old copy to compare so
I wasn't sure what had changed. I also wanted to give the people with
Aetna a heads-up.
— cabingirl
August 28, 2003
Thanks John! You are right. When I read it at like 4:00 this morning I
read it the other way. This way makes a lot more sense to me. Shows I
should have been asleep rather than up since 2:30 am.
— zoedogcbr
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