Question:
Did anyone, whose surgery was approved, have Aetna POS, and an exclusion?

I have Aetna POS (as opposed to HMO or PPO) and my policy excludes any coverage for obesity at all, including drugs and surgery. I have already run into problems with this exclusion with trying to get my referral approved for a consult with a surgeon. I found out that the nurse at my PCP's office didn't even submit it for approval or denial because of this exclusion. Can anyone let me know if their referrals were denied by Aetna with this type of exclusion?    — M. M. (posted on May 29, 1999)

July 10, 1999
My wife had no problems getting a VBG approved, but she also has over 5+ years documented as having a hiatial hernia and GERD. Our insurance is Aetna PPO thru US Healthcare. It took about a month to review the claim, and rejected the original surgery approved (RNY), but recommended the VBG to help her 'kill two birds with one stone'...
   — [Anonymous]

July 17, 1999
You have my support & sympathy. I have the same problem...Aetna PPO usually pays, but Microsoft (Hubby's employer) has a written exclusion. I am very depressed. Good luck to you. Warmly, Laura
   — Laura S.

August 7, 1999
Yes I have Aetna US Healthcare QPOS/HMO but in Florida. they also have an exclusion. I believe it reads "not covered unless approved by Medical Director" or something like that. Do not despair. They will approve. However, expect a first denial and you will have to appeal. For the appeal be prepared to prove you have had medically supervised diet programs. Be warned they take longer in the appeals process then they claim. Do not get worried. If you fail during your first appeal, immediately request a second of Level II appeal hearing. And push forward. They approved me during the first appeal but my BMI was in the 70's and my wife w/BMI of 46 was approved in the Level II appeal stage. Hope I was of help and if you need further info, please contact me.
   — Samuel D.

Click Here to Return