Aetna Insurance questions - help please

I have Aetna POS insurance and it covers 90% for the lap-band® surgery. Well, someone mentioned to me that though the surgery is covered, you have to go through 6 months of recorded weight loss attempts with your doctor. Well, I know that I have some record with my doctor and I want to get a jump start on exactly what I will need. No one will tell me. In 2005 I had my twins, so I don't have a record for 2004 and 2005. My first consult isn't until June 25th, but if I need to start seeing my doctor before that I want to get going on it. Please, please, please give me feedback. I'd like to get a jump if I can. I am 36 years old, 243 pounds, 5 feet 7. I also previously went to a diet doctor in late 2005 for diet pills, but it wasn't with my PCP. I am just confused on what to do.

I have Aetna also....I had to do the 6 month diet and I had to have a recorded history of obesity for 2 years. The history can come from any doctor ie. OB/GYN or a combination of doctors that combined show that you have a total of 2 years of recorded obesity from an MD.

Hi twinmommy, I also have Aetna POS that covers 90%after my deductible. I made an appointment with my general practioner(sp) (Who I've only seen once in about the last 6 years) I told him what I was needing to have done, He was very understanding telling me that he had had some other patients that needed the same things that I was asking. So I scheduled 6 appointments roughly a month apart. We talked about my eating, exercising and things that I was trying to do to prevent myself from overeating or staying away from the junk. Needless to say I really wasn't doing these things, but these were the "things" that we needed to discuss for his notes every month.
I also had to see a dietician. I paid $50 for a 1 hour consultation with a registered dietician from Hyvee the local grocery store. Sometimes these professionals are less than one from a hospital or office building. I also had to have a psychological evaluation from a psychiatrist. No problem there, because I already see one. Basically they needed a letter from her saying that she thought that I was of sound mind to make my own decisions and to do the things to help maintain the things that I needed to do to renforce the decision I had made. They bascially don't want to have anybody with a major psychiatric problem to undergo this surgery and not be on board with the things you need to do to make this work. Alot of my weight records came from my OBGYN. They were the only doctor that I saw pretty regulary. They also want you to write down all the diets that you have tried or been on. I really didn't have any dates for anything except Slim 4 Life and Weight Watchers. So alot of the dates I just kinda made up. Who could remember decideing on "May 27, 2008 at 1600 hours that I thought I would try the South Beach Diet again". Crazy!!!! :I hope this answers some of your questions, Sorry to have gone on so much, But all this is pretty fresh in my mind. I finished my 6 month eval in January and was approved in April. Good Luck! Susan

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Thread Starter

Thank you everyone for all of your feedback. Maybe I'll sign up for a nutritionist soon. I hope it doesn't take too long after my consultation.

I have Aetna POS II also and went on their website and printed out their specific requirements. Then I brought it to my doctors. There was no denying or monkeying around with what was required by everyone

I have the choice II plan and only need to do 3 mos. of a documented diet. But really... use their website, its a great resource. Also...CALL THEM!!! Get the tellers name every time you call so you have someone to contact later or document that you have requested information.

Good luck


Deb

Hello,

Here is my input on the whole thing. I did the three month diet and now Aetna is looking for six months? Ok their bulletion says you can do three if you do a multi-discplinary. Which is what I did. I paid $1200.00 to do it but I figured it was worth it. Now Aetna is not playing by their rules and requesting six months of documentation! Give me a break! Part of the problem is the nurse at my Dr.'s office didn't send it in the first time around. She said Aetna doesn't need that! If the nurse tells you they don't need the recoreds that she is an idiot! I probally would have been approved by now if the nurse would of just sent it the correct info like I told her she needed to send in. So instead of being approved right now I am waiting and waiting. It took the nurse two weeks to send in the paperwork that she did now another two weeks have gone by. She said Aetna takes a full thirty days to approve. Yeah that is because the nurse doesn't do her job and slows the whole process up!!!

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Approved June 9th 8:22am!!!!

Surgery Scheduled July 15th!!!!
Total lbs to date 63.8lbs!!
1 1/2cc today in a 10cc band
Woo Hoo....

I have Aetna and did the three month multidisciplinary approach too. I was fortunate that my LAP-BAND® doctor offers at a fee of $25 a month, monitored my plan and documented my 3 months of successful program.

I joined a gym at my local hospital for a medical approach exercise program, they do an initial eval and set up your routine. I have a card I clock my visits in on and can easily request a print out of my visits to proof my activity requirement. This membership cost me $26 a month and I still go 3-4 times a week.

I work at a hospital and I know a few nutritionist ... they kindly did a free professional eval, and set me up on a weight loss diet and typed up a letter for my doctor and insurance. I had been seeing a psychologist for the past couple years and she did my psych eval and sent it to my doctor.

There are tremendous hoops to hop through, but keep a folder, write everything down, go on aetna's website and get your requirements.
The surgeons office should give you a form letter for your family doctor and requirements. I got alot of info at the free seminar. Also check out the official LAP-BAND® site from the manufacturer.

Good luck and stay strong!! It was worth it!!!!!!



Tess

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Tess

It is not about perfection... It's about progress!!!
Lap Band Surgery 03/10/2008
First Fill 05/05/2008 3.5cc Second Fill 08/20/08 2.5cc Third Fill 01/13/09 2cc

Sorry to hear about your hastles, but I've got the same dilema. I went to Weight Watchers for over 9 months, and my Dr. knew about it, but I did not see him for 6 continuous months or see a nutritionist so they are denying me my surgery. I also went to Curves for 1 year. I'm so frustrated that right now I've said the heck with it. I've submitted documentation 3 times to them and still am denied.

I sure hope you have better luck with Aetna than I did.

Interesting to hear this because I was just recently denied because Aetna said I had to have the 6 months of documentation. I've gotten frustrated and said the heck with it. I've already done 9 months of Weight Watchers and only lost 20 lbs., done Curves. Nothing is helping.

I have Aetna Pos II also. I printed out the criteria from their website. Went to the surgery center who monitored my diet and exercise for three months, turned in the required number of years of health history showing my weight, went to a dietician (only 2 visits), went for a pysc eval, which wasn't even required but I figured what the heck. It was one visit that lasted 10 minutes! I also went for the sleep apnea test. Wasn't required either. I have diabetes, but figured if I had two co-morbidities it would help my case. Submitted to ins. and was approved. It took them a whole month to get back to me with approval, but in the end it was worth the wait. Had the surgery and feel awesome. It was the best idea I ever had to get the LAP-BAND®.

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Dr. John Marsden-DFW
Surgery 3-14-08

Greetings everyone,

Thanks for sharing your experiences with AETNA. I'm just completing my six month supervised diet and my concern is that I actually didn't lose any weight during the six months--I actually gained (I lost the six months prior to being medically supervising using Weight Watchers and attending 2-week program at Duke DFC). When I read the requirements from the AETNA website, it doesn't say that you actually have to be successful at the weight loss during the six month period, just supervised. My PCP agrees and says that there are many reasons for situations like mine and if anything, the weight gain shows that I do need the help that the LAP-BAND® will provide so he will provide the letter of medical necessity anyway.

However the Doctor at the Bariatric program where I participated in six-month supervised diet feels that surgeon will not perform surgery because of the recent weight gain (although I'm still well within the parameters) and most importantly that AETNA will NOT even consider or approve my application for the surgery -- VERY DISCOURAGING.

Has anyone had this experience? Specifically with AETNA either approving or denying the application although recording a weight gain during their six month supervised program?

I do appreciate your replies, remarks and sharing! Thank you in advance for your continued generosity of spirit and support!!!

Daniel in Atlanta

P.S. I'm still trying to decide between a surgeon at Emory Crawford Long Hospital and DeKalb Medical -- any feedback on either?

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Daniel in Atlanta
Believing and working toward a healthier me!

Wow you had a fantastic experience with Aetna from the sounds of it. I hope to have the same...

Deb

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hello everyone, I just found out my Aetna insurance does not cover LAP-BAND® although my doctor said that I was a excellent candidate and the band was needed. Does anyone know if there is an appeal process for this? any help would be great.

I have Aetna as well. I have a BMI over 40 and two co morbidities. I did the 6 month program with regular doctor and I have been denied. I am meeting with my doctor tomorrow to find out what is going to on.

Anyone have experience with the second appeal process?
thanks
Dennis

Hi Silvers,

Why did they deny you? Did they give you a reason? If your bmi is over 40 you don't need to have any co-morbities. Did you do a three month or a six month diet? Did you submit all that paperwork in as well. I am currently waiting for Aetna to make a decision about my case. They are dragging their feet. I really hate Aetna.

__________________
Approved June 9th 8:22am!!!!

Surgery Scheduled July 15th!!!!
Total lbs to date 63.8lbs!!
1 1/2cc today in a 10cc band
Woo Hoo....