aetna approval?

dimples · 11-22-2005, 03:19 PM

Does anyone use aetna and have been approved? is it hard to be approved by aetna?

**Alexandra** · 11-22-2005, 05:28 PM

Dimples, as with any other insurer it's impossible to generalize. What does your contract say? Is it a large employer group that writes its own benefits? Or are you in a standard sort of small-group plan? What are the mandates in your state for coverage? All of those questions have more bearing on whether you will be covered than Aetna's corporate philosophy.

dimples · 11-22-2005, 06:35 PM

Thank you so much for answering my thread. I am sooooo new to this. I have read so much about this lap band surgery in the last 2 weeks, I am soooo scared that I will not get approved for my surgery. I called aetna and they said the lap band surgery is a part of their insurance plan I have to just followed the doctors instructions, and do what is required of the plan. I guess that means the 100lb over weight thing and bmi score. I am 280lb's right now and can't even sit comfortable at my computer desk to write you. I saw you on the sit please help me though this. I just want to cry sometimes.

**Alexandra** · 11-22-2005, 07:22 PM

Aetna was no picnic to deal with when I went through the process in 2002/3, but I hope they've changed their tune by now. You will have to fill in all the forms, answer all the questions, get all the tests and have your doctor write all the letters, but if your plan covers bariatric surgery you should be able to make the case that banding is preferred for you.

One thing Aetna did well, I thought, was make its requirements very clear. Make sure you read it ALL before you get started; they make their list available on their website so you shouldn't get stuck with any surprises if you are prepared. Your doctor, if he's done any of this before, will also know a lot about what he needs to provide.

Good luck, and try to be patient! I know it's hard, but it's SO worth it in the end. :)

DrHekier · 12-01-2005, 10:29 PM

From Aetna's clinical policy bulletin ( http://www.aetna.com/cpb/data/CPBA0157.html )

I have cut and pasted just one small section here from the entire bulletin.

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Vertical Banded Gastroplasty (VBG) and Laparoscopic Adjustable Silicone Gastric Banding (LASGB or Lap-Band):

Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) or laparoscopic adjustable silicone gastric banding (LASGB, Lap-Band) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following comorbid medical conditions:

Hepatic cirrhosis with elevated liver function tests; or
Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or
Radiation enteritis; or
Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or
Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV) (see Appendix).

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Basically it appears that they would prefer you to get a gastric bypass because it appears to indicate that a Lap Band would be approved only if you are a poor candidate for a gastric bypass.

**Alexandra** · 12-02-2005, 09:06 AM

Quote:

Basically it appears that they would prefer you to get a gastric bypass because it appears to indicate that a Lap Band would be approved only if you are a poor candidate for a gastric bypass.

That is essentially it, but there are more reasons than those listed that might make someone a poor candidate for bypass. Use your imagination and don't be afraid to bring in family history and mental state when talking about why RNY isn't for you. (By mental state, I mean that the difference in speed of weight loss between the two surgeries might be a strong selling point for banding for some people. The two experiences are very different, and will have a different impact on the patient.)