Denied By Aetna!! Wth?!

[brandyrn73 13]

To say I'm frustrated is an understatement! I've spent the last 7 months doing EVERYTHING that was asked of me by the medical center/Aetna and I found out today that I was denied because I haven't been morbidly obese for at least 2 years (I've been 100 lbs or more overweight for MANY years) and I have no comorbidities. I am 5'5'" 232 lbs. I have GERD, a hiatal hernia, high cholesterol and rediculous hypothyroidism since my thyroidectomy 10 years ago. My previous case manager at the bariatric surgery clinic led me to believe these would be sufficient for Aetna, hence why I went through the long, tedious process to be approved. The case manager in charge of my case now apologized but what good does that do me?!

What ticks me off is that my husband and I work hard in this life, and we pay $$$ for our insurance coverage. But when I go to actually use it I'm told I'm not qualified. WTH! Apparently being 100+ lbs overweight isn't fat enough?! They would rather wait until I'm sick from hear disease, hypertension, etc then help me get healthy NOW. It just doesn't make sense to me.

Self pay isn't an option for me. I'm waiting to hear if I can just pay for the band when I get my hernia repaired. Hopefully I'll know tomorrow. The case manager said we can appeal and that could take 30-60 days. I have a feeling that will be denied too.

[FLORIDAYS 3,040]

Self pay isn't an option for me. I'm waiting to hear if I can just pay for the band when I get my hernia repaired. Hopefully I'll know tomorrow. The case manager said we can appeal and that could take 30-60 days. I have a feeling that will be denied too.

I know you are disappointed. I too had Aetna and was 217 lbs over weight with a 55 bmi , high bp and was denied. I didn't think self pay was an option either until I spoke to my dr and the hospital and found they offered Interest free payment plan with some cash down. Not a credt company...just the hospital. then about 2 mths after banding they called and offered 50 on the dollar to me which we took them up on. Interestingly enough the Insurance paid for the psych eval, pre op bloodwork and nutritionist appointment which I thought was ironic.

[prinxs 41]

Find out the appeal process for your insurance. You can write an appeal letter!

[Randi Cartmill 23]

What company you work for?

[brandyrn73 13]

I'm a nurse and work in the hospital setting.

[brandyrn73 13]

This sounds a little familiar...

http://wlsappeals.com/winning-bariatric-surgery-insurance-appeals/

[angelize 50]

this is my fear too! my surgery is scheduled for oct 5...and im waiting to hear from ghi if i will be approved. all the doctors and nurses have told me not to worry.....but all i keep thinking of is getting denied after jumping through all these hoops!!!

[brandyrn73 13]

I haven't even seen the surgoen yet much less got a surery date! Tomorrow I will speak with my surgeon's secretary and find out if I can go ahead and schedule my hernia repair. This insurance game is STUPID.

[Sojourner 2,446]

Yes, insurance is convoluted and frustrating...and I'm truly sorry to read of what you are having to go through.

I agree that the reasoning Aetna appears to have used in their decision is flawed in a major way. I also went through Aetna for my surgery...however I had several weight related comorbidities.

The insurance coordinator at your surgeon;s office should know the exact words to use in your appeal process.

Good luck...and never give up!

[Mandylove 32]

I had the same thing happen to me last month! Jumped through all the hoops, my surgeons office told me everything looked good, did all my per-op appointments and then DENIED for not showing 2 years of morbid obesity. It's like they deny you for having tried to loose weight in the past, and succeeding but then gaining it back?! My surgeons office then told me there was nothing they could do but send me to an appeals program. It was just sent in for appeal today so my fingers are crossed it gets over turned!!! I feel for you!! It's such a bad feeling especially when your hopes are up! Good luck!!

[cunner 21]

Brandy (and Mandy),

This is such a common topic with Aetna. I Soooo hate their policies!!! They have to be the worst insurance company when it comes to WLS.

I see from you post that you have found the Lindstrom Advocacy group. Do yourself a favor and call them right away.

When I spoke with them they asked me to send all of my information and then Kelley took over from there. She handled all communication and Appeals with Aetna. It cost me exactly $0 for everything she did.

Two years ago this week I got my 4th denial letter from Aetna. When Kelley called me to explain that this was part of the process and it is just what we wanted I believed her. She was right! In less than a month I get a phone call saying that my appeal was overturned in the final external independent review process.

I had been banded for 21 months now and I am below my goal weight.

I have posted a link to one of my earlier posts with a followup. Do a search for "Aetna" and you will see how difficult they can be.

Please do yourself a favor and stick with it. I have no idea if Aetna will ever change but there are ways to beat them.

Good Luck !!!

http://www.lapbandtalk.com/topic/108409-2nd-denial-so-disappointed/page__hl__aetna#entry1528023

[Mandylove 32]

@Cunnar! Thanks so much for sharing! That gives me hope. My question for you is when you worked with Lindstrom Advocacy what was the time frame from calling them to approval?? They told me 90 days from when they send your first appeal but I have heard getting to the independent review takes time. Any info would be greatly appreciated!

[Dawn200321 146]

I was shocked and sad to read this. I had a fantastic experience with aetna. I had a bmi of 43 and high blood pressure and was approved first try. They wanted 3 years of weight history and I was even missing one year and one year was when I was pregnant. I hope you go through the appeal.process and get approved

[Sojourner 2,446]

Brandy (and Mandy),

This is such a common topic with Aetna. I Soooo hate their policies!!! They have to be the worst insurance company when it comes to WLS.

I see from you post that you have found the Lindstrom Advocacy group. Do yourself a favor and call them right away.

When I spoke with them they asked me to send all of my information and then Kelley took over from there. She handled all communication and Appeals with Aetna. It cost me exactly $0 for everything she did.

Two years ago this week I got my 4th denial letter from Aetna. When Kelley called me to explain that this was part of the process and it is just what we wanted I believed her. She was right! In less than a month I get a phone call saying that my appeal was overturned in the final external independent review process.

I had been banded for 21 months now and I am below my goal weight.

I have posted a link to one of my earlier posts with a followup. Do a search for "Aetna" and you will see how difficult they can be.

Please do yourself a favor and stick with it. I have no idea if Aetna will ever change but there are ways to beat them.

Good Luck !!!

http://www.lapbandta...na#entry1528023

It's not just Aetna when it comes to having to navigate through reams of red tape to get approval for surgery...I have had to deal with many insurance companies through the years both as a subscriber member, and as a medical services provider.

Every insurance company offers many plans...so it may be the level of coverage that your policy provides and not the insurance company that causes the additional issues with the approval process.

In my experience with Aetna, from both the provider and subscriber perspectives, they were one of the better insurance companies to work with...as opposed to Tricare and Cigna.

Others mileage may vary...

[cunner 21]

Sojourner, I am sure many insurance companies can be difficult. The shortsightedness that they practice is a sad fact. There are a great deal of posts specific to Aetna and WLS in this forum. Of course I am probably biased as that is what I focus on. In my case I have the most comprehensive (and expensive) plan offered through my company. Still I had issues.

Mandy. I went back to view my saved messages from Walter Lindstrom. The 1st one through the approval message:

April 17, 2010: Thank you for contacting us about your LAP-BAND insurance denial. From the information you provided on our website form, it appears you may qualify for Allergan's LAP-BAND appeals/advocacy program.......(it goes on after this)

October 29, 2010 (to my surgeons office) : Kelley and I wanted to let you know we were successful in our appeal of his denial with Aetna and we appreciate the opportunity to assist your patient obtaining life-saving treatment......

It seems like forever when you are living through it but don't give up. I had so many emails between this time from Kelley keeping me updated and reassuring me that it was going as planned. I know you would/will like her. It was impossible not to.