Question:
Insurance problems, five year criteria why don't they really care?

Right now I am fighting my insurance on having the Gastric Bypass Surgery. The only hold up is the five year criteria. It will be five years for me this June 2004. The insurance won't approve me because of two months. Does anyone know of anyone that has been approved two months short of five years? The insurance said if I can find a publication of such I would be approved. If not, I have to change insurances at the end of this month (March 2004). I will have to start all over again and that is really hard to do. My new insurance will be with Aetna. Can anyone please help me?    — Tammy P. (posted on March 12, 2004)

March 11, 2004
More than likely, Aetna will just want 6 months of documented diet history. They want to see that you went to your primary doctor for 6 months regarding your weight. They want documented that you talked about diet and exercise. Good Luck
   — Mandybub

March 11, 2004
If you're changing to Aetna PPO, they (as long as your employer chooses to cover WLS) are normally pretty easy to deal with as long as you meet their requirements. Here's a link to their requirements. http://www.aetna.com/cpb/data/CPBA0157.html They also require 5 years of documented obesity (BMI greater than 40 or greater than 35 with co-morbities) as well as 6 months physician supervised diet, exercise, visit with nutritionist, etc. Even if you would be lucky enough to get approved with your current insurance, you probably wouldn't have your surgery by the end of the month when you have to change insurance. If I were you, and you know that your policy with Aetna will cover the surgery, I would concentrate on meeting their requirements. If you already have some sort of dr. supervised diet within the past 2 years, you won't have to worry about that. Aetna will accept Weight Watchers or other program as long as your PCP has noted it in your records that you're attending. You do not have to see a nutritionist referred by your physician - I found one at my local YMCA that was very cheap and you just need to make sure your PCP has documented everything in you medical records (including nutritionist consult, prescription of exercise - even walking, supervised diet). Good Luck.
   — Carolyn M.

March 19, 2004
Just call Atnea and find out the criteria. Also, sounds like this insurance co. is STALLING you....Good Luck in your journey. Ann
   — Ann M.