Finally Approved after 2 Appeals! Thought I was denied after talking to hubby...Whew

[MustangKitten 0]

I thought that I would get an approval after the first submission since I had what was considered a solid submission. My BMI is 53 and has been for over 10 years, I am 33 years old, have had 3 children no plans for more. I did my psych eval, my nutritionist consult, got letters from my primary, had the diet history done, had a fitness consult, everything. I was ready to go. Well Aetna denied me on the first round because I did not have documented weight from 2008. I had it from 06, 07, 09, and 10 but not 08. They only needed at least 2 years so I was baffled by that. But I held my head up and said no worries, I will just appeal and things will be fine. Well they denied my appeal. At this point I was frustrated, I was feeling like I have always felt, sad, depressed, a sense of doom. I gave myself a week to "grieve" and be depressed and then I said NO! I am not going to take no for an answer. I know in my heart that I am a good candidate for this surgery and I am not going to let some pencil pusher at an insurance company tell me no. I worked with my surgeon's office doing the appeals because I am clueless to what I needed and didn't need. The insurance coordinator in his office is awesome. This is all she does. So we put our heads together and I said, look I don't have any documented weight from 2008 but I have a ton of pictures. I had professional photos taken at an annual charity event that I attend every year. It has the date real big on the front of the picture. That combined with all the documentation was submitted for my third and final try.

Here is where the story gets funny. Well it wasn't funny then but I can laugh about it now. I go out out town on Sunday and come back late Monday night. I'm tired from the drive so I come home and go straight to bed. Don't even ask my husband about the mail, which wouldn't have mattered sicne he didn't bother to check it while I was gone. But for some reason he decides to check it on his way to work (4am). We talk about 8:30am when I am on my way to class and he tells me I got some bad news in the mail and I was denied again. He said "I'm sorry and we wil figure out a way to get it done." I was upset, I started crying. I felt hopeless. I was asking him a million questions about what it said and he was like, I didn't read it all carefully, I just glanced at before I got to work. He left the letter in his car (which was an hour away) so I had to wait til that evening when he got home. I immediately contacted my insurance coordinator and told her what happened. We were looking into outside reviews, possible hiring an obesity attorney, anything. So my husband gets home that night about 6pm and hands me the letter. Istart reading it and it says blah blah blah..in reference to your denial of bariatric coverage.....blah blah blah...our decision....blah blah blah....we are reversing our previous decision and allowing bariatric coverage...blah blah blah. I was shocked. I looked at him and started crying again. I was half laughing and half mad and I said, "Are you f*%#@^g kidding me?" He stared at me and said, "What?" I said, "This isn't a denial, they are reversing their decision, this is an approval! Do you realize what you put me through all day?" and we both started laughing. I told him that his mail checking privileges are revoked and from now on my mail stays in the mailbox til I get it and can read it. It was too late to call my insurance coordinator so I sent her a few e-mails and she called the next morning. We were laughing about it then and she asked me if I slapped him for the hell I went through the day before. I said no because I was too happy about the approval.

Anyway, I know this is a long story but I wanted to let some people know, do not give up after the first denial or even the second. If you have a solid submission and you know you are a good candidate for the surgery, then you need to stand up and fight for it. My surgery is now scheduled for Nov 29th and I couldn't be more ready for it. I was ready for it when it was originally scheduled for Nov 1st so I am even more ready. Good luck to everyone!

[reverie 49]

Congrats on your approval! Just proof that sometimes you have to push and push, but it does pay off.

[DizzyGirl 0]

WOW! What a long journey you've been on for the Band! I'm proud of you and Good Luck to you on the rest of the way. Way to stick with it and know what's best for you.

[cunner 21]

Awesome !!! Way to stick with it. My sugery was scheduled for last march before Aetna started me on the denial path. Mine ended up going to external review before getting overturned. I got help from Kelley and Walter Lindstrom at obesitylaw.com. Kelley was so great I cant say enough about how helpful she was making me feel better throughout the process. I am scheduled for 12/29. One month to go. It has already been 11 1/2 months since I started this process.

Good Luck and congratulations again

[happygirl65 5]

Way to go! I would SO revoke his mail reading privledges too....lol. I laugh because my hubby does the same thing....reads things then hands it to me and says...tell me what it really says....lol.

EXCITING!