Aetna insurance

Hello everyone,   I recently switched jobs and have aetna insurance now, and I was wondering how they approve the surgery. I desided on the DS after getting approved for the RNY, before I switched jobs.  I am excited, and wanted to thank everyone on this site who is so nice. I havent been on in about a month with the job change and move, but the first post on the DS site I did,made me feel so wonderful and not alone. Thank you everyone!!!!!!!!!!!! hugs,

You have to meet the criteria listed on the aetna website. Go to the website.  I had aetna and was approved. From memory, i had to have 3 month surgeon supervised diet and exercise regime pysch evaluation 5 CONSECUTIVE years of medical history - showing that my bmi was always over 40 (or over 35 if you have treated comorbidies) i also threw in a medical neccesity letter for kicks.  You can read my story on my profile..dig in the archives for all the details.  Good luck.

Thank you Hayley! I looked on the website and it kinda confused me, you have given me great relief! The 5 year history wont be a problem! I cannot wait to get this weight off and feel better, and I am so glad I have decided on the DS! hugs,

My insurance company website confused me alot too, but when I talked to my surgeons office she was better able to give me the details of what I needed.  She had much more information than anyone at the insurance company could give me! Good luck with everything

Thank you so much,  I was so confused after reading the website, I really couldnt tell if they did or did not!  I am going to check out the website you love also. thanks again, esther

I have Aetna and I just have to finish up my registered dietician stuff (I switched from BCBS/IL mid-stream so the requirements were a little different). Here is what my Aetna baratric surgery policy says, in summary: they will cover the DS, but you have to:  A) have a 5-year history of a BMI over 40 or a 5-year history of BMI of 35 with some major comorbidities (heart disease, type II diabetes, sleep apnea or hypertension).  B) Be age18 or over, for complete bone growth  C) Have tried to lose weight before without success D) Have to show you have been doing a PHYSICIAN-SUPERVISED nutrition and exercise program for six months or longer within the last 2 years. At least three of the months MUST be consecutive. A doctor's note or Jenny Craig/Weigh****chers records are NOT enough. You have to have detailed notes from both your registered dietician and physician to back this up--weigh-ins, a food plan, etc.   E) Not have severe psychiatric issues that would compromise your ability to give informed consent or follow the WLS regimen for the rest of your life.   In my opinion, letter D is where most people have trouble. They don't have a doctor who is taking good notes or willing to go to bat for them. They've hit bottom and have given up on diets and exercise and can't imagine doing it again for six more months, plus being supervised/judged during that duration. I know from experience that Aetna is a stickler for this part!!! I have posted the full Aetna policy below, too. However, do NOT just take anyone's advice here or elsewhere as to what your particular policy will cover. We mean well, but we don't know everything. Talk to Aetna or your surgeon's insurance coordinator--don't worry, they're used to these questions. The Aetna person will probably just refer you to their web site. I have found that they do not want to be on the hook for interpreting their policies, they just want to point you in the right direction. Your surgeon's insurance coordinator is your friend and they should know what they're talking about. It's their job to get you approved, because it's money in their doctor's bank. So, use them!! Good luck! Nicolle

Aetna’s Policy on Obesity Surgery

 

Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures:

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 or Lap-Band) medically necessary when the selection criteria listed below are met.

Selection criteria:

1.      Presence of severe obesity that has persisted for at least 5 years, defined as any of the following:

1. Body mass index (BMI)* exceeding 40; or

2.      BMI* greater than 35 in conjunction with any of the following severe co-morbidities:

1. Coronary heart disease; or
2. Type 2 diabetes mellitus; or
3. Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna  CPB 004 - Obstructive Sleep Apnea); or

4.      Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);

and

2. Member has completed growth (18 years of age or documentation of completion of bone growth); and
3. Member has attempted weight loss in the past without successful long-term weight reduction; and

4.      Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary surgical preparatory regimen):

1.      Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet all of the following criteria:

1. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
2. Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least three consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.); and

3.      Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records;

or

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:

1. Consultation with a dietician or nutritionist; and
2. Reduced-calorie diet program supervised by dietician or nutritionist; and
3. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
4. Behavior modification program supervised by qualified professional; and

5.      Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen. (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.)

and

5.      For members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, a pre-operative psychological evaluation and clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and postoperative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.

Hello and thank you for your help. That is exactly what happened to me.  I had BCBS/NC and it was realy simple, no supervised diets or anything like that. Im dissappointed that it seems like I will be stating over in a sence. I really appreciate your help.  Thank you, esther