2nd denial... So disappointed !!

[cunner 21]

I don't even know what to write to express how disappointed I am right now. Have gone through every required appointment including Upper GI, Endoscopy, 2 EKG' 2 sleep studies up though completing my pre-surgery admissions and was less than 36 hours from my scheduled surgery date at one point a couple weeks ago. The only thing missing was insurance approval.

The surgeons office does not submit an insurance packet until a surgery date is set. With my date set at 3/31 I find out that they didn't submit the packet until 2 weeks prior. With me calling Aetna everyday to check the status and being told it is still under review I finally get a call from the surgeons office on the morning of 3/30 telling me they will have to reschedule. My denial came on the morning of 4/3. According to my surgeons office it was due to the fact that I had been diagnosed with sleep Apnea but had not had my CPAP long enough before surgery. The hospital didn't schedule the pulmonary consult until 3/29 so until that time I didn't even know the results of the sleep study.

So now I am on CPAP and have a new date scheduled on 5/12 and insurance packet is resubmitted for new date. Yesterday I got a second denial stating that according to the submitted records by BMI fell below 35 at a point within the past 2 years. On December 08 I was 1# light. Prior to that I had been lower due to working very hard to lose the extra weight. I am now a 38 BMI and have records indicating a BMI of 37 as far back as '04. I went up and down constantly during that time. I also have high blood pressure, high Cholesterol, GERD and Sleep Apnea. It seems my biggest mistake according to the insurance company policy is trying to lose weight. I thought that is what they would want me to do.

I was now told by the surgeons office that my only recourse at this point is the write an appeal myself but that in the meantime I will be removed from the active patient list and they couldn't help me anymore.

Due to 1 pound my next record showing my weight wasn't until June2009 and I would need to maintain where I am until June 2011 or abandon it all together. The NP coordinator at the sugenons office told me that was a poor decision and I should try to live a healthy lifestyle and decide if I want that extra piece of cake or if want to be take care of myself better. WTF have I been doing for the past 10 years and look where it got me.

Maybe I will lose weight as I didn't sleep at all last night and I haven't been able to eat anything today since I am so disappointed. It is so hard to have any confidence that an appeal with be met with any other outcome than I have already heard.

[Pretty14yah 0]

So sorry about your denial. I know how important this process is. Don't give up. Try and stay positive and believe that if it is meant to be it will happen. Good luck with your Journey.

[sweetsagi 28]

Hi Im so sorry that you are having such a difficult time with the insurance.:cool: I read someone's post before that suggested obesitylaw.com. for what its worth i think you should give them a call and explain the situation. Dont give up just yet because thats exactly what the insurance comapny wants you to do. hang in there. Good luck with everything.

[cunner 21]

Thanks for the replies. I am getting over my self pity. Yesterday was tough and I needed to vent. I am ready to move on and start formulating my appeal.

I do have a few questions and seek some advice on a couple of things I would like to say in the appeal but I think maybe I will open a new thread so that people will not have to get through my frustrated ramblings to get to my questions. Thanks again for listening. :-)

[arends1 0]

Hi,

Sorry to hear about your 2nd denial. I totally understand your frustration. I also have been denied twice. I am now starting the appeals process. I was told to have your dr.'s and family members write letters in regards to your health and weight. My BMI dipped to 38 in 2007 then I became pregnant and they are using that against me its very frustrating. Let me know how it goes.

[sweetsagi 28]

Hi Again

I just wanted to add that I too was denied by my ins company but it was because of the 6 months medically supervised diet. I called obesitylaw.com just today (dont know why I waited so long) and I was told that they have a program in place that helps in situation like this when u are denied, and here is the best part... ITS FREE! they will represent you and handle the whole appeal. I was told by the attorny that the program has been in effect for almost four years (sponsered by the makers of LAP-BAND®) but for some reason not a lot of people know about it. So maybe it just might be worth giving them a call.

Let me know how it works out.

[Cocoabean 430]

My computer is making me mad! I had a great response going and IE crashed on me. So, let's try this again!

You post breaks my heart! These insurance companies will do anything to get you to go away, so DON'T go away! This makes me sooo mad! Prepare yourself for a loooooong post!

I've been looking for a copy of my appeals letter, but I can't seem to find it. I wrote it nearly 3 years ago. The computer I wrote it on is gone.

While working on your appeal, don't give up on you. Also..if it were me, I'd not try to lose any weight. Time marches on, and 2011 will be here before you know it.

Anyway, the book Weight Loss Surgery for Dummies has some very good appeals letters examples. Also, search "weight loss surgery appeal letter" on the internet and you'll find some other samples.< /p>

I quoted this in my appeal and included a copy. You can find a PDF version online.

In 1991 the National Institutes of Health wrote a Consensus on Gastrointestinal Surgery for Severe Obesity Here's the link: The National Institutes of Health (NIH) Consensus Development Program: Gastrointestinal Surgery for Severe Obesity

No where does it mention how long you have to be obese to have surgical treatment.

The next section (in blue) is a quote from the NIH subsection of NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases)

WIN - Publication - Bariatric Surgery for Severe Obesity

The first bullet is the one to hit on strongest. Yes, you dipped below a BMI of 35 by ONE pound for ONE visit. Point out that is the difference between seeing the doctor in the morning vs. the afteroon or wearing shorts vs. jeans. Or a new/different scale. Are their scales certified by weights and measures? There was a law suit against Weight Watchers about their scales, and that they could not charge lifetime members who were over goal because a member got on one scale and was over, walked over to the scale right next to it and was not. So now, at least in San Diego, all their scales are calibrated and certified.

Do you have a history of being above 35 before that and after that? If so, then state that you cannot keep weight off, you NEED surgical intervention. Just because you lost some weight for a short period does not mean you were cured, obviously.

Bariatric surgery may be the next step for people who remain severely obese after trying nonsurgical approaches, especially if they have an obesity-related disease. Surgery to produce weight loss is a serious undertaking. Anyone thinking about undergoing this type of operation should understand what it involves. Answers to the following questions may help you decide whether weight-loss surgery is right for you.

Are you:

• Unlikely to lose weight or keep it off over the long term with nonsurgical measures?
  
• Well informed about the surgical procedure and the effects of treatment?
  
• Determined to lose weight and improve your health?
  
• Aware of how your life may change after the operation (adjustment to the side effects of the operation, including the need to chew food well and inability to eat large meals)?
  
• Aware of the potential risk for serious complications, dietary restrictions, and occasional failures?
  
• Committed to lifelong healthy eating and physical activity habits, medical follow-up, and vitamin/mineral supplementation?
  

Speak of how your obesity affects your life. How your co-morbidities drag down your quality-of-life. Explain that you know you will have work to do when you are approved, but you know that this surgery is going to help you avoid expensive treatments for diabetes and cardiovascular disease.

What you want is to live a normal, healthy life with your family!

Best wishes!

[arends1 0]

Denise,

I found your post very helpful and it seems that after you appealed you must have been approved. So, I am hoping this works. If not I will try again in 2011 time goes by fast anyways and it will not be long till its here.

Thank you,

Selina

[cunner 21]

Thank you Denise and Sweetsagi. This information is very helpful. I am also a firefighter and there are countless studies and statistics I can site that show heart attacks being the leading cause of firefighter line of duty deaths. These state that obesity, hypertension, high Cholesterol and stress being the leading causes of heart attacks. Thanks to the insurance co I can now add stress to my risk factors ( I won't mention that) :thumbup:

If I stay above 35 until 2011 and resubmit I expect the hospital will make me go through most of the testing again as it will be about 1 year later. I am curious if mentioning that fact and pointing out that those are additional costs that were already paid by insurance that would be incurred again is a good idea or if it will piss them off. I don't want to sound like I am threatening them but I don't intend to drop below 35 BMI and reset my 2 years. If I meet the criteria are they not then obligated to pay? I guess that might be a question I can ask at obesitylaw.

[Cocoabean 430]

Glad to be of help. I hope you all win the appeals!

For some reason, this topic just really ticks me off. I can't think of any other medically necessary treatment that people have to fight for to receive--but there are probably some out there. When my father needed triple bypass surgery, he did not need to beg and plead for it. He was in surgery the day after it was identified that he had blockages.

This is elective, yes, but when our insurance says it is covered and we elect to go for it, they should work WITH us, not against us.

Yes, I won my appeal. My situation was like Sweetsagi's. I was denied even seeing my surgeon due to the 6 month requirement. I submitted Weight Watchers records among other things and won.

Time being what it is, over 6 months passed before I got my band, but I did not have to wait 6 months before getting through the starting gate to see my surgeon.

Cunner, I would point out in a very professional way that the tests will likely no longer be valid in a year's time and need to be repeated at great expense to them and you. Some of them are invasive and painful.

I also had the thought go through my head that you can point out how when you hit the 1 lb below 35 BMI you were dieting at the time, and that is a time when you dress in your ABSOLUTE lightest clothing to see your doctor to weight in.

Why do they make you go through those tests before even looking at your history? Why would they not do a 'pre-approval' of some sort to look and see if you even sort-of qualify before paying for those tests?

Do contact obesity-law. I don't know anything about them, but it is another resource. Remember, too, the Americans With Disabilities Act. Look into that and see if you can throw that into the letter. Being a Fire Fighter, you might not want to go there, but something well worded might help. Give them all you got!

Ok, rant done! Oh, and DON'T say you are't dieting or that you plan to gain weight...think you prolly know that :thumbup: Everything you say may be used against you.

Best wishes to you all!!!!

[cunner 21]

I just wanted to update my old thread. I did contact obesitylaw and worked with Kelley. She is awesome by the way. After my first 2 denials Kelley at obesitylaw submitted an appeal which was denied followed by a 2nd level appeal which upheld the denial. Aetna simply would not acknowledge that I had any co-morbid conditions. The last appeal is an independent external review which is done by an agency (bariatric surgeon) with no relationship with the insurance company. I heard back yesterday that the denial was reversed and that Aetna has to cover the surgery. They looked at the evidence and determined that my BMI and the presence of several co-morbid conditions made me a good candidate for lapband surgery. I can't express how happy I am :thumbup:

I am on my way to Disneyworld this weekend with my family. Hopefully this will be the last time ever that I have to be concerned with what rides I will fit on.

This is a journey that I started last December. My goal is that I will have surgery before the December 14th date one year ago that I first walked into the meeting to start this process.

Insurance companies can make it so hard and frustrating but it so important to hang in there and not give in to them.

[Cocoabean 430]

I just wanted to update my old thread. I did contact obesitylaw and worked with Kelley. She is awesome by the way. After my first 2 denials Kelley at obesitylaw submitted an appeal which was denied followed by a 2nd level appeal which upheld the denial. Aetna simply would not acknowledge that I had any co-morbid conditions. The last appeal is an independent external review which is done by an agency (bariatric surgeon) with no relationship with the insurance company. I heard back yesterday that the denial was reversed and that Aetna has to cover the surgery. They looked at the evidence and determined that my BMI and the presence of several co-morbid conditions made me a good candidate for LAP-BAND® surgery. I can't express how happy I am :thumbup:

I am on my way to Disneyworld this weekend with my family. Hopefully this will be the last time ever that I have to be concerned with what rides I will fit on.

This is a journey that I started last December. My goal is that I will have surgery before the December 14th date one year ago that I first walked into the meeting to start this process.

Insurance companies can make it so hard and frustrating but it so important to hang in there and not give in to them.

Cunner, I am so pleased you continued the fight and won!! Thank you for updating on your original post.

Congratulations to you! Please, please stick around here to help others with appeals. Just your experience with this will help. Being able to point them in the right direction is awesome.

I help whenever I see posts such as yours, but my information is somewhat dated now as I went through it a few years ago and won on my first appeal.

Please enjoy Disneyworld with your family. The next time you go you will be a healthier you!

Just a note, I first started looking into surgery sometime in June or so, had my surgery the following February. So I was about 8 to 9 months in the process. If you get done in one year, that is really not too bad for all the fighting you had to do.