Question:
Does anyone know what Aetna POS requires before getting approved for surgery

   — sadiebelle (posted on August 4, 2008)

August 4, 2008
If you go to www.aetna.com/cpb/medical/data/100_199/0157.html the website actually has the guidelines. Hope this helps
   — B. Jones

August 4, 2008
Yes, I agree with the previous post. You need to get the info from them as it can vary from day to day (as my experience working with an insurance company proved). ALso, if it's insurance through an employer, then often the employer will set the guidelines so that someone with the same insurance through a different emplioyer can have different insurance. You need to get the exact information so that you have something concrete to go on, not information from a third party. IN general, however, they all require about the same thing: If they cover WLS at all, then they will generally need proof from your doctor that there is documentaion of you being obese for a period of time (2 to 5 years), that you have tried other methods of losing weight and not been successful. That you have a BMI of at least 40 (35 and up BMI with two co-moribidities...high blood pressure, diabetes, sleep apnea being the most common co-morbidities). Sometimes they require that you go on a 6-month (or more) managed weight managed documented by a doctor or dietician as a last ditch effort to lose weight before WLS. It is the job of hte insurance company, in my opinion, to make it as hard as possible for you to get the surgery which of course saves them a lot of money. It's important that you check your insurance manual to see (in writing) what is covered or not....then talk to the insurance company. For me it was hard to find two people at the insurance company who even said the same thing. Finally I was turned over to a nurse who was my care coordinator. She told me that even though it stated in my handbook that I would be covered, that they had recently decided NOT to cover it without first requiring the 6-month diet even though it didn't say that in the handbook. SO 2 months into the diet, they reversed the decision and said I didn't need the diet. However this was near the end of the calendar year and I think they were going to completely exclude it for the year 2008 so I just go in. Good luck...keep trying...hope this helps.
   — cjjordan