Question:
Does anyone know what Aetna POS requires before getting approved for surgery
— sadiebelle (posted on August 4, 2008)
August 4, 2008
If you go to www.aetna.com/cpb/medical/data/100_199/0157.html
the website actually has the guidelines. Hope this helps
— B. Jones
August 4, 2008
Yes, I agree with the previous post. You need to get the info from them as
it can vary from day to day (as my experience working with an insurance
company proved). ALso, if it's insurance through an employer, then often
the employer will set the guidelines so that someone with the same
insurance through a different emplioyer can have different insurance.
You need to get the exact information so that you have something concrete
to go on, not information from a third party.
IN general, however, they all require about the same thing:
If they cover WLS at all, then they will generally need proof from your
doctor that there is documentaion of you being obese for a period of time
(2 to 5 years), that you have tried other methods of losing weight and not
been successful. That you have a BMI of at least 40 (35 and up BMI with
two co-moribidities...high blood pressure, diabetes, sleep apnea being the
most common co-morbidities). Sometimes they require that you go on a
6-month (or more) managed weight managed documented by a doctor or
dietician as a last ditch effort to lose weight before WLS.
It is the job of hte insurance company, in my opinion, to make it as hard
as possible for you to get the surgery which of course saves them a lot of
money.
It's important that you check your insurance manual to see (in writing)
what is covered or not....then talk to the insurance company. For me it
was hard to find two people at the insurance company who even said the same
thing. Finally I was turned over to a nurse who was my care coordinator.
She told me that even though it stated in my handbook that I would be
covered, that they had recently decided NOT to cover it without first
requiring the 6-month diet even though it didn't say that in the handbook.
SO 2 months into the diet, they reversed the decision and said I didn't
need the diet. However this was near the end of the calendar year and I
think they were going to completely exclude it for the year 2008 so I just
go in.
Good luck...keep trying...hope this helps.
— cjjordan
Click Here to Return