Question:
I am a bunch of nerves...reagarding approval with Aetna HMO
I have Aetna HMO. My husband works for a small company no more than 500 employees. Out of that I think 80 of them or less use the plan. I have already called aetna and they said it is covered as long as it is medically necessary. We pay 147 every two weeks plus the company contributes 70 dollars a month. Is this a self funded plan? My papers get submitted next week and if I am denied I will just die. We never received a list of exclusions from the company. I hate being in the unknown. Thanks Dana — Dana N. (posted on April 25, 2001)
April 25, 2001
If Aetna said that it is covered as long as it is medically necessary then
they can't have it as an exclusion. It does not sound like it is a
self-funded plan. I have included below an excerpt someone else included
from Aetna's website (www.aetnaushc.com)
Aetna
Approved after appeal letter (08/06/00)
Laparoscopic RNY
Weeks to approval : 4
Pre-Op BMI : 50.8
Comorbidities : sleep apnea, gastric reflux
Policy : Must be medically necessary
Comments : The Aetna policy on the surgery is posted on their web
site. I did not initially provide documentation of medically supervised
weight loss. Once I did the surgery was approved. *****
Aetna Policy: Subject: Obesity: Surgical Treatment
Aetna U.S. Healthcare covers the surgical treatment of obesity when the
following criteria are met:
(These criteria were adapted from the NIH Consensus Conference on Surgical
Treatment of Morbid Obesity.)
1.Presence of morbid obesity, defined as a body mass index (BMI)* exceeding
40 or greater than 35 in conjunction with severe co-morbidities such as
cardiopulmonary complications or severe diabetes; AND
2.documented history of repeated failure of physician-supervised
medical/dietary therapies. *****
*BMI is calculated by dividing a patient's weight (in kilograms) by height
(in meters) squared. To convert pounds to kilograms, multiply pounds by
0.45 To convert inches to meters, multiply inches by .0254
Candidates for revision of gastric restrictive surgery must have a
complication of the original procedure, such as obstruction or stricture.
In addition, revision of gastric restrictive or bypass surgery, which has
failed due to dilation of the gastric pouch, is appropriate if the original
procedure resulted in weight loss prior to the pouch dilation.
Aetna U.S. Healthcare does not cover ANY of the following procedures
because the peer reviewed medical literature shows them to be either unsafe
or inadequately studied:
Loop gastric bypass;
Gastroplasty using staples to create a small pouch;
Duodenal switch operation;
Biliopancreatic bypass
Laparoscopic adjustable silicone gastric banding using the LAP-BAND
Note: As a high incidence of gallbladder disease (28%) has been documented
after surgery for morbid obesity, Aetna U.S. Healthcare covers routine
cholecystectomy in concert with elective bariatric procedures.
Background: Accepted surgery for morbid obesity, termed bariatric surgery,
includes gastric restrictive procedures and gastric bypass.
The gastric restrictive procedures include vertical banded gastroplasty and
gastric banding which attempt to induce weight loss by creating an
intake-limiting gastric pouch by segmenting the stomach along its vertical
axis. The process of digestion is more or less normal.
Gastric bypass combines gastric segmentation along its horizontal or
vertical axis with a Roux-en-Y procedure, such that the food bypasses the
duodenum and proximal small bowel. Because the normal flow of food is
disrupted, there are more metabolic complications compared to gastric
restrictive surgeries, including iron deficiency anemia, vitamin B-12
deficiency and hypocalcemia, all of which can be corrected by oral
supplementation.
Several studies have suggested that gastric bypass is a more effective
weight loss procedure than vertical banded gastroplasty, offering the best
combination of maximum weight control, and minimum nutritional risk.
While appropriate surgical procedures for morbid obesity primarily produce
weight loss by restricting intake, intestinal bypass procedures produce
weight loss by inducing a malabsorptive effect. Biliopancreatic bypass
(also called jejunoileal bypass or the Scopinaro procedure)
consists of a subtotal gastrectomy and diversion of the biliopancreatic
juices into the distal ileum by a long Roux-en-Y procedure; the result is a
200 cm long alimentary tract, a 300 to 400 cm biliary tract, and after
these two tracts are joined at the distal anastomosis, there is only a 50
cm common absorptive alimentary tract. It was designed to address some of
the drawbacks of the original intestinal bypass procedures which resulted
in unacceptable metabolic complications of diarrhea, hyperoxaluria,
nephrolithiasis, cholelithiasis and liver failure. Although this procedure
is reported to have a higher rate of weight loss, it is rarely performed in
the United States due to the high risk of various metabolic complications.
Gastroplasty, not to be confused with vertical banded gastroplasty, is a
technically simple operation, accomplished by stapling the upper stomach to
create a small pouch into which food flows after it is swallowed. The
outlet of this pouch is restricted by a band of synthetic mesh, which slows
its emptying, so that the person having it feels full after only a few
bites of food. Patients who have this procedure seldom experience any
satisfaction from eating, and tend to seek ways to get around the operation
by eating more. This causes vomiting, which can tear out the staple line
and destroy the operation. Overall, about 40% of persons who have this
operation never achieve loss of more than half of their excess body weight.
In the long-term, five or more years after surgery, only about 30% of
patients have maintained a successful weight loss. Many patients must
undergo another, revisional operation, to obtain the results they seek.
Although the basic concept of gastric bypass remains intact, numerous
variations are being performed at this time. Recent data demonstrate that
surgeons are moving from simple gastroplasty procedures, favoring the more
complex gastric bypass procedures as the surgical treatment of choice for
the morbidly obese patient. The gastric bypass operation can be modified,
to alter absorption of food, by moving the Roux-en-Y-connection distally
down the jejunum, effectively shortening the bowel available for absorption
of food. The weight loss effect is then a combination of the very small
stomach, which limits intake of food, with malabsorption of the nutrients
which are eaten, reducing caloric intake even further. In a sense, this
procedure combines the least-desirable features of the gastric bypass with
the most troublesome aspects of the biliopancreatic diversion. Although
patients can have increased frequency of bowel movements, increased fat in
their stools, and impaired absorption of vitamins, recent studies have
reported good results. The loop gastric bypass developed years ago has
generally been abandoned by most bariatric surgeons as unsafe. Although
easier to perform than the Roux en-Y, it creates a severe hazard in the
event of any leakage after surgery, and seriously increases the risk of
ulcer formation, and irritation of the stomach pouch by bile.
Recent advances in laparoscopy have renewed the interest in gastric banding
techniques for the control of severe obesity. Recently, laparoscopic
adjustable silicone gastric banding (LASGB) using the adjustable LAP- BAND
has become an attractive method because it is minimally invasive and allows
modulation of weight loss. Their advantage is the adjustability of the
band, which can be inflated or deflated percutaneously according to weight
loss without altering the anatomy of the stomach. This method entails
encircling the upper part of the stomach using bands made of synthetic
materials, creating a small upper pouch that empties into the lower stomach
through a narrow, non-stretchable stoma. The reduced capacity of the pouch
and the restriction caused by the band diminish caloric intake, depending
on important technical details, thus producing weight loss comparable to
vertical gastroplasties, without the possibility of staple-line disruption
and lesser incidence of infectious complications. However, distension of
the pouch, slippage of the band and entrapment of the foreign material by
the stomach have been described and are worrisome. The FDA has not yet
approved this device and procedure for use in the United States, and so it
still is considered investigational.
Please check their web site at
http://www.aetnaushc.com/cpb/data/CPBA0157.htm to get the latest
information and references for this policy.
Source: [email protected]
— Mary H.
April 25, 2001
Hi, I have Aetna HMO....and work for a small company also...According to my
surgeon's office, Aetna is one of the easier insurance companies to deal
with....I have a high BMI 51 - The MA from my surgeon's office called
Aetna, and received an approval over the phone...and I received my approval
letter from Aetna three days later...now I know it is not always this
easy...but after reading the insurance posts for my state (Ohio) it sounds
like they are fairly good to work with!! Good Luck, Karan
— chance2lv
April 25, 2001
I have Aetna, they approved me on the phone with the doctor in two days, A
week later I got a letter of approvel.
My doctor said Aetna was one of the best,,,,,Plus uou don't have to go for
all those extra tests, with the other insurance companys. make you go
through.
— Marie B.
April 25, 2001
My husband works for a small company that uses Aetna HMO and I was approved
in TWO DAYS!
— PT LawMom
April 25, 2001
Don't worry! Aetna is the best when it comes to approving WLS. I was
approved in 24 hrs & got the approval letter a week later. As long as
you qualify.. BMI of 40 OR 35 W/ Comorbs.. you'll be fine! Godbless!
— sgeisendorff
April 25, 2001
I also have Aetna HMO. I was approved within 2 weeks. My sister-in-law had
no problems getting approved with them either. Best of luck to you.
— Pamela B.
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