aslcertified

Oh and by the way , Aetna (case manager) said I am only allowed one level appeal and external review is not allowed under my plan So I did a little digging and pulled up my benefits and researched , then called Aetna and was told a different story. I am allowed an external appeal and my denial letter indicate that I am allowed not only one but two appeals plus an external review. This is unbelievable !!!! Sent from my iPhone using the BariatricPal App

Sent from my iPhone using the BariatricPal App I hope you can read it ! Sent from my iPhone using the BariatricPal App @@dede0314 thank you. Sent from my iPhone using the BariatricPal App @@KristenLe thanks Sent from my iPhone using the BariatricPal App

Yes I will fight. Sent from my iPhone using the BariatricPal App I hired lindstrom advocacy and they are fighting with this with me Sent from my iPhone using the BariatricPal App

Received message with the net weight gain photo but doing more research and found out by talking with dr office today and they said I did not gain , I actually lost weight start 6/2015 240lb to 9/2015 at 239.5 so I'm not sure what is going on. Maybe Bec The dr office submitted my paperwork to insurance comp two weeks after the 6 month deadline to schedule my surgery , I have no idea. Sent from my iPhone using the BariatricPal App

oh wow I found the perfect forum, I am working with lindstrom as well. I hired them jan 2016 to help with my case to overturn my denial, but just last week they denied my appeal but lindstrom is not giving up without a fight they are an awesome team. The reason they are saying my surgery was denied bec of net weight gain 1.5 lbs and my surgery was not scheduled within 6 months of initial date. we questioned them over and over again , " when was I suppose to have scheduled the surgery if you already denied right after the 3 month pre-op requirement" ?. all Aetna could do is read my policy to us 20 times UGHHH! . I was so hurt and disgusted by this I could not believe it and I was going over it in my head about everything asking myself, where could things have went wrong? no way 1.5 lbs gained would be such a big deal bec you cant calculate 1.5 lbs as a major weight gain. So many factors can cause a 1.5 gain. clothes , time of month anything etc....... at this point , I was confused and I started to do a little digging on my own today 7/27/16. so, I called my dr office and asked what were my weigh in's which I should have been monitoring and keeping track of everything from insurance coverage to all my weigh in info. /initial start date 6/2015 240 , 7/2015 245 , 8/2015 242, finial weigh in 9/2015 239.5 .. MY MOUTH DROPPED! ok so where is this 1.5lb weight gain they are talking about, what was the real reason for denial???? so I am thinking the ball dropped with someone or am I missing something here ? has anyone experienced this before?

That's a great idea too !!

My first appt , the coordinator did not say anything about a 6 month pre-op. She just said well Aetna requirement is 3 month and she gave me a check off list of the things I need to do and numbers to call to set up my appointments within the 3 month period. I really did not know about the 6 months requirement until I received my benefits coverage summary. But as I reveiew the summary , I think they were following my co morbitities and which criteria I fall under and just told me To do the 3 month pre-op Bec I had all what the ins needed for approval me vs what they needed for the 6 months. So it all depends. But was definitely not told about the net weight gain , I was told that oh just as long as you do not gain 4 to 5 lbs or lose too much weight that would cause your bmi to go below the requirement for surgery you would be fine. They were shocked just as much as I was , and not well informed about the specifics but I should have read the information for myself instead of depending on them to know it all. So please please what ever you do not not gain any weight and get a copy of your coverage and read it throughly before you start spending money then be disappointed but if you stay within guidelines I know you will be approved whether it's 3 or 6 months.

Yes I agree do not gain weight not even an ounce.

Thank you ! I will check it out

I FEEL YOUR PAIN!!!! UGGGGGGGGHHHHHHHHHHHHHH I want to scream !!!!!!!! Yes,I completely understand the frustration, I too, have been denied in Dec and I hired an advocate to fight this denial. all of my paperwork was submitted with my first appeal and just last week 7/22/16 they upheld the denial even though I have one of the co morbidities listed and I have followed the 3 month program monitoring for surgery. so my advocate called Aetna on a conference call and the Medical general surgeon (who is not a bariatric surgeon) who made the decision to deny my claim was not helpful AT ALL! she just kept reading from a script explaining the details of my policy which we already knew. so finally, Dr says, bec you did not schedule your surgery within the 6 months of your initial start date and you gained 1.5 lbs your claim was denied. start date was 6/25/16 - 9/16/16 paper work submitted for authorization and immediately denied. COME ON' 1.5 lbs, that could be anything from clothing, time of the month ..... anything !!! I can see if it was a significant weight gain like 10 lbs. they need to have more so we are going for a second appeal and I really need to find out if I am spinning my wheels or do I just need to start over... I wish there is something more we all can do to fight the insurance companies to stop denying surgeries for the simplest thing.

does anyone know, if the denial is upheld how long do a person have to wait to start the process over again?

Good Morning everyone! I needed some feedback and support regarding insurance not paying for bariatric surgery, I also have Aetna POS here in Louisiana and I too went through the 90 day program one of Aetna requirements, I fit all of the criteria and just last week received noticed I was denied because I gained 1 lb and did not schedule my procedure within 6 months of my initial start date. I was in shock, upset, and very disappointed. how can this be, initial program date 6/25/15 last weigh in date 9/16/15 and immediately was denied, I researched and hired obesity advocate /attorneys to fight this since Dec 2015 to start the first appeal process and last week the appeal was denied because I gained 1 lb. I do not understand that policy, I weighed in summer which means my clothes were lighter, then last weigh in was September which my clothes would have been a little heavier 1 lb is not a significant amount of weight to consider because 1 to 2 lbs can come from many factors such as clothes, time of the month, or if I had a snack or lunch prior to the appointment my clothes alone would weigh 1 to 2 lbs COME ON'. I can understand if I gained 5 lbs to 10 lbs of weight. OMG!! I want to scream...... Has anyone experienced AETNA denying surgery for weight gain and then was approved after it was appealed first or second time? Now we are going for round 2 and want to know if it is worth it bec I am so disappointed with Aetna. HELP!! please ADVISE!!

Good Morning everyone! I needed some feedback and support regarding insurance not paying for bariatric surgery, I also have Aetna POS here in Louisiana and I too went through the 90 day program one of Aetna requirements, I fit all of the criteria and just last week received noticed I was denied because I gained 1 lb and did not schedule my procedure within 6 months of my initial start date. I was in shock, upset, and very disappointed. how can this be, initial program date 6/25/15 last weigh in date 9/16/15 and immediately was denied, I researched and hired obesity advocate /attorneys to fight this since Dec 2015 to start the first appeal process and last week the appeal was denied because I gained 1 lb. I do not understand that policy, I weighed in summer which means my clothes were lighter, then last weigh in was September which my clothes would have been a little heavier 1 lb is not a significant amount of weight to consider because 1 to 2 lbs can come from many factors such as clothes, time of the month, or if I had a snack or lunch prior to the appointment my clothes alone would weigh 1 to 2 lbs COME ON'. I can understand if I gained 5 lbs to 10 lbs of weight. OMG!! I want to scream...... Has anyone experienced AETNA denying surgery for weight gain and then was approved after it was appealed first or second time? Now we are going for round 2 and want to know if it is worth it bec I am so disappointed with Aetna. HELP!! please ADVISE!!

Good Morning everyone! I needed some feedback and support regarding insurance not paying for bariatric surgery, I also have Aetna POS here in Louisiana and I too went through the 90 day program one of Aetna requirements, I fit all of the criteria and just last week received noticed I was denied because I gained 1 lb and did not schedule my procedure within 6 months of my initial start date. I was in shock, upset, and very disappointed. how can this be, initial program date 6/25/15 last weigh in date 9/16/15 and immediately was denied, I researched and hired obesity advocate /attorneys to fight this since Dec 2015 to start the first appeal process and last week the appeal was denied because I gained 1 lb. I do not understand that policy, I weighed in summer which means my clothes were lighter, then last weigh in was September which my clothes would have been a little heavier 1 lb is not a significant amount of weight to consider because 1 to 2 lbs can come from many factors such as clothes, time of the month, or if I had a snack or lunch prior to the appointment my clothes alone would weigh 1 to 2 lbs COME ON'. I can understand if I gained 5 lbs to 10 lbs of weight. OMG!! I want to scream...... Has anyone experienced AETNA denying surgery for weight gain and then was approved after it was appealed first or second time? Now we are going for round 2 and want to know if it is worth it bec I am so disappointed with Aetna. HELP!! please ADVISE!!