Hello!
I posted about a month ago, asking questions about banding. From there I prayed, and researched (more) and decided the band is exactly to tool I need to succeed with my weight loss goals.
I've so confused about all the insurance stuff. I called member services and they said the surgery is coverage and gave me a link to the clinical policy bulletin which reads...
Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met. Selection criteria: A. Presence of severe obesity that has persisted for at least the last 2 years, defined as any of the following: - Body mass index (BMI)* exceeding 40
My BMI is 53 (good lord), and I have high BP.
It also says naturally that you have to over 18 and done growing, attempted weight loss in the past without success in long term reduction, and meet either criterion 1 (physician-supervised nutritional and exercise program) or criterion 2 ( multidisciplinary surgical preparatory regimen).
I am working with a weight management and bariatric surgery center near me. I have to complete consults, and tests with all sorts of different people on the team including attending support groups, and lose 5% of my body weight before surgery - it's a 3m process. So I'm assuming this meets criterion 2. Aetna words it like this:
- Criterion 2. Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three months duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions:
- Consultation with a dietician or nutritionist; and
- Reduced-calorie diet program supervised by dietician or nutritionist; and
- Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
- Behavior modification program supervised by qualified professional; and
- Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen at each visit. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.)
Sounds like my program right? I called my Aetna AGAIN to be sure they cover this surgery and she again assured me that it is covered so long as I meet the criteria and to bring the criteria to my NP consult. I know I have to wait to be approved after all my testing etc, but I'll (like anyone else) be so gutted if I'm denied.
Anyhow, I'm waiting for June 30th for my NP consult and I'm so excited!! I've been reading everyone's stories and looking at before and after photos and I'm so impressed with the lot of you!! So inspirational.
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