AETNA:
My experience with Aetna has not been bad, so far. They have some pretty strict requirements; but, if you follow the "rules" it seems to be fairly pain free. Here are the requirements that apply to me and how I'm documenting it. Some of the requirements have an "or" component that does not apply to my situation...for the sake of relative brevity, I am not including those here. If you're interested, you can find the complete Clinical Policy Bulletin for Obesity Surgery here.
Presence of severe obesity that has persisted for at least the last 2 years (24 months), defined as any of the following: Body mass index (BMI)* exceeding 40: Aetna recently changed this requirement from 5 years to just 2 years. Documenting this requirement took some legwork. I called both my PCP and gynecologist to ask for copies of my records from the last 3 years. I took the single record with the highest weight for each year and am including that in my file (I was advised that too much information can be confusing for the reviewer and hinder the process. Send the minimum requirements and if more info is needed, they will ask). To supplement my doctor's records, I created a chart that showed my weight and BMI for each year.
Member has completed growth (18 years of age or documentation of completion of bone growth): A copy of my driver's license will suffice to prove that I am 39 and have "completed growth".
Member has attempted weight loss in the past without successful long-term weight reduction: another chart (The chart isn't displaying properly--Click here to view as a webpage) documenting my weight loss efforts over the same time period. My PCP also agreed to write a letter confirming that I have been unsuccessful at maintaining clinically significant weight loss while under her care.
In deets & digits (part 2) I will cover the 3 month multi-disciplinary pre-surgery regimen that is required by Aetna.
2 comments:
Glad to hear Aetna changed 5 years to 2 years. I had my surgery in August covered by Aetna and had to have 5 years of my weight and 6 months of monitored weight loss.
This process is lengthy but it's worth it!!
http://betterbanded.blogspot.com/
I think the 3-month "multidisciplinary surgical preparatory regimen" option was implemented around the same time as the 2-year change. It is my understanding that a patient who has already participated in a 6-month physician supervised weight loss program within 2 years of surgery can do the documentation stuff and straight to the surgeon w/o the waiting period.
I've been following your progress and am encouraged by your success. Keep up the good work!
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