Thread: Will Aetna Insurance Cover??? Surgery...?

I've been looking into the Lapband Procedure and my Insurance, Aetna, will cover if I have any of these three listed co-morbid diseases: Diabetes, Hypertension or Sleep Apnea. I don't have any of those but I have a huge hereditary background of Diabetic family members including close family such as: Father, Grandparents, Aunts and Uncles. However I have Asthma. I know there is a way longer list of co-morbid diseases so will those three be all that they will most likely stick by or is there a chance that mine can be approved even though they only state the three I listed above???? Pls only those in the health insurance business or those who have had personal experience. Thanks!

Aetna will probably not divert from the three listed conditions, which can be life threatening to morbidly obese people. LapBand surgery is expensive, and getting insurance approval for it is not easy. Most insurers will require that you attempt conventional weight loss, under medical supervision, for at least one year before they will approve the procedure. If weight loss measures under medical supervision fail, only then will they consider authorizing the procedure. Additionally, you must qualify as morbidly obese (at least 100 lb. over ideal weight) before you will qualify.

I don't think they're going to cover it, unless you can get a diagnosis for one of those other three.

Are you SURE you don't have sleep apnea? That might be the easiest to get a diagnosis for . . . and also would be the easiest one for you to overlook.

Well, first you have to verify that you don't have any exclusions for weight loss/bariatric surgeries on your policy. (One employer who has benefits through Aetna may choose to exclude weight loss surgeries from coverage, while another employer with benefits through Aetna might allow it on their policy as long as Aetna's medical guidelines were met.)

After that's done (if you haven't already), that's when the evaluation process starts. Keep in mind that the insurer has to stick very closely to what their corporate medical policy states for approving a particular procedure is...otherwise, if they make an exception for one person, they have to make that same exception for everyone.

I've not seen Aetna's corporate medical policy/criteria regarding lap band surgery. However, I'm quite familiar with the policy of a few other large insurers, and have seen files for multiple patients who were approved for the surgeries and also multiple files for patients who were denied for the surgeries. It all comes down to whether or not you meet the specific criteria that Aetna has established a person must meet to be approved...its highly unlikely that any exceptions to their medical policy would be made.

Your best bet in trying to figure out whether you meet the criteria is for either you or your physician to get a copy of Aetna's official medical policy/criteria for lapband surgery. Then you and your physician can review this information together to determine how to proceed...if you feel that you meet/exceed the criteria set forth by Aetna, then move ahead with requesting pre-approval for the procedure.

Only you and your physician can confirm whether you meet the criteria. If what you're asking us here is whether or not an exception can be made if you *don't* meet the criteria, unfortunately I'd have to tell you that its unlikely. (Again, the corporate medical policies are set for a reason...to establish specific cutoffs for approval so that the insurer knows where to draw the line between who gets approved/who doesn't. The minute one person gets an exception, then the insurer opens themselves up to all kinds of liability from other people who've been denied. So, if you and your physician don't think that you meet Aetna's criteria or at least are a close borderline case that should be reviewed, I would not get my hopes up too much about getting approved.)

Good luck...and definitely review a copy of Aetna's medical criteria with your physician to see where you stand!

After that's done (if you haven't already), that's when the evaluation process starts. Keep in mind that the insurer has to stick very closely to what their corporate medicaAfter that's done (if you haven't already), that's when the evaluation process starts. Keep in mind that the insurer has to stick very closely to what their corporate medical policy states for approving a particular procedure is...otherwise, if they make an exception for one person, they have to make that same exception for everyone.


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