Aetna PPO requirements - ThinnerTimes

Puddin · 06-07-2008, 07:52 PM

I've just recently started my journey and had a question about the Aetna requirements. It says that they need 5 year history of being overweight. Does that mean that I have to have been considered morbidly obese in that time? My BMI was probably down between 34-38 for a year or two in that 5 month time frame. I was also pregnant during that time too. Does that get added in there? I now have a BMI of 44.9, have elevated blood pressure, insulin resistance, and reflux. Base on your experience, could I still be denied?

BabyNicole · 06-07-2008, 09:09 PM

Well, if they said 5 years of being overweight, it's pretty easy to be overweight these days.

For my height (5'3") 155lbs is overweight.

So, I'm guessing even if you were any amount over the "normalcy" on the charts, you will be okay (but I don't have Aetna). I believe it goes: underweight, normal, overweight, obese, morbidly obese, super obese. If they give you shite b/c you weren't morbidly obese for 5 years say, "Hey! You said overweight!"

Good luck, hon!

AmityA · 06-07-2008, 09:47 PM

I had Aetna PPO and i was pregnant twice during the 5 years that they wanted. When we submited, Aetna said that they changed the requirement to 2 years. I made that easy. pregnancy weights do not count in your weight history.

Also, they denied me the first time and my clinic did a peer-to-peer review the next day and the Aetna Dr who denied me approved me for the surgery. I had my surgery date later that same day.

Good luck!

moniram8 · 06-08-2008, 12:00 AM

I have Aetna myself and when i started this process back in Nov 2007 I was told it was a 5 yr weight history as well. But when my surgeons office pre-certed my surgery in March of this year, they were told that Aetna did change their requirements to only 2 years. Which was probably a life saver for me, because there was plenty of times in the past 5 years that i vistited my doc's office, where i just waved off the scale when they asked me to get on it....cause lord knows....i didnt want ANYONE else but me knowing exactly what # was gonna pop up on that dreaded scale.
Also, something else you can do.....investigate your insurance coverage. Make sure they cover Lap gastric bypass in your policy, ask them if they cover procedure code 43644 and/or 43645. Also have your surgeons name and the name of the hospital handy and find out if they are in or out of network with your insurance as well. I used a surgeon and hospital that were both in-network and the surgery LITERALLY cost me $0 !!!!!!
Good Luck
Michele

KathyV · 06-08-2008, 12:28 AM

I have Aetna now after 15 years of BCBS. The weight part was so easy all I had to do is get 5 weigh ins from any Dr. (one for each year) I flexuated from 190 to 234. It could have come from an urgent care or just a regular visit. I was certain that if I was 230 on year one and then 135 year 3 and back up to 190 on year 5 I would have still qualified.

Now my husband's work put in a 10,000 life time limit on Gastric Bypass and even though I told the hospital that and they agreed to do it on a 5900.00 day fee they had the gaul to bill me 31,000. after it was all done. It is a mess but by Monday hopefully it will be all straightend out.
The bad part about all this is now my husband is really thinking ofhaving the operation. But 10,000 dosn't get much on this surgery. And the Dr. I went to in the Desert all though very good charges a lifetime program fee of 6500.00 on top of the other charges. You get alot for the money but if my husband does this we will be looking for a cheeper Dr.

I had my surgery 3/10/2008 and they still required the 5 years but again no big deal for me. I have been fat along time.

Puddin · 06-08-2008, 08:22 AM

According to my Dr's office, my firm's insurance covers both surgeries. I meet all the requirements so now it's just proving that to the insurance company.