Denied because of 1.8lbs!

[The Icy One 518]

What process did u have to go thru for ur insurance?? I have Aetna also was it hard to get a reponce??

I have Aetna. My plan doesn't require a referral so I just went directly to True Results in Scottsdale (the Lap Band practice that I chose), made an appointment and they took it from there. Most established WLS practices have working with various insurance companies down to a fine art, know what each company wants and can guide you, step by step through the process.

My advice is to do a little research online, find your local WLS practices, choose one or more that interest you, call, talk to a patient adviser, ask questions, he or she can tell you what your insurance requires to get you started and will guide you into beginning your process. Some will book you right in for an initial appointment, others may require a seminar, first. I didn't have to do a seminar. I just went in for an appointment and we were off and running. Some places let you make the initial appointment online. My practice did and followed up by e-mail.

[The Icy One 518]

Well, today was my final four visit check in. After my insurance company threw me a curve ball and changed up the rules on me, I dieted like a madwoman, hoping I could get to the weight I needed to to qualify. Heading down to the Valley, today I was sweating bullets. When I got to True Results, I got on the scale and...

I just eked it out.

Whew! I am so relieved. Now, I have to wait for the submission and approval process. They told me it could take four to six weeks.

*cue up Final Jeopardy music*

[skikyd 165]

So I will tell you all the reasons I should have the band- BMI of 55 Heart attack at age 32 I am 34 now High BP Depression Pseudotumor Cerebri with severe papillo edema Hx of Pulmonary embolisms Pre Diabetic Reason Aetna denied me today- I gained 1.8 pounds since May!- they said they would have denied me with even an ounce gain. They implemented this new rule this month. I have been jumping through the Ins hoops for four months now. I was suppose to get banded Sept 27 instead I have two more weigh ins I am crushed.

Ohhhh that sux.

Do it. Drop the weight. Show them.

You can do it.

[Irishflower79 183]

Sorry I have been MIA but been depressed over the denial.My surgery was suppose to be tomorrow makes me sad I don't get to start my journey yet.

I went for my 5th visit on Sept 23 and was down 10lbs!

They were going to submit again and see if I still have to do another weigh in Oct 21 or not. I will call Monday or Tuesday of I have not heard anything yet.

My PCP sent in an appeal on my behalf also.

[sylvia42 43]

Good luck Irish , everything will work out , maybe this was meant to be.. I have to wait till next June so don't fell bad...

[B-52 7,113]

Are you saying they denied you because you GAINED WEIGHT? That's ridiculous...that's why we need the WLS because we cannot, or have a very difficult time loosing weight any other way....

When I went through this phase, 2 things I remember...I was looked at on a different scale and a different set of criteria because of the co morbidites....they actually made it easier to get the approval....even my PCP knew this and it was the main reason he referred me...my health issues....and bleak prognosis...which only loosing weight and changing lifestyle would cure.

2nd...the 6 month required medical supervised diet, in my case, had nothing to do with loosing weight.....it was to show, as part of my record signed off by a physician, along with charts, grafts, and weekly progress notes, that I did make a sincere effort to loose weight and FAILED! Thereby proving that surgery was the last, and perhaps only resort for me to loose weight and re-gain my health.

And sure enough, just as I did in every other diet I have ever took part in, I started out great, then eventually leveled off, then reversed and failed...I lost weight, but by the time the program was over I was steadily gaining it all back....

Next thing you know Insurance Companies will start denying people because they will argue... "See? You CAN loose weight on your own...you don't need surgical intervention"

My...how the rules have changed.....the girls in my office deal with insurance submissions all day...and thy have gotten very good at it....it takes a lot of documentation, and you need to get past their first line of defense which is usually minimum wage staff who know nothing about medical issues but are trained to spot "Red Flags"..certain words..and kick the claims back without even looking at the entire picture...

You know Insurance companies consider "Bathing" a "Luxury" and "Not Medically Necessary?"

But this is what your Surgeons office does every day....deals with the ridiculous with appeals...."The squeaky wheel gets the oil"

[The Icy One 518]

Sorry I have been MIA but been depressed over the denial.My surgery was suppose to be tomorrow makes me sad I don't get to start my journey yet.

I went for my 5th visit on Sept 23 and was down 10lbs!

They were going to submit again and see if I still have to do another weigh in Oct 21 or not. I will call Monday or Tuesday of I have not heard anything yet.

My PCP sent in an appeal on my behalf also.

Yay you!

I hope that you get your approval, this time.

[2muchfun 8,927]

It will be interesting to see how Obamacare(affordable healthcare act) looks at WLS?

[eatoandc 33]

I can't imagine what you feel but at least you still have a chance ... Maybe focus on that positive...

[Irishflower79 183]

Thanks everyone for all the replies. I should hear by tomorrow if the appeal was approved or if I have to have one more weigh in Oct 21.

[rose6850 29]

What process did u have to go thru for ur insurance?? I have Aetna also was it hard to get a reponce??

I got my Aetna approval on Friday and it was pretty easy. 4 months of supervised nutrition visits, meet their minimum BMI (or BMI and comorbidity) requirement, and don't gain any weight from your first visit to your last. Easy peasy!!

I asked Aetna why on the no weight gain rule and apparently there are studies showing a much lower success rate for people who gain pre-op weight. It can cause more surgical complications and shows a lack of dedication and knowledge about what is required for a banded lifestyle. Makes sense to me, it just sucks people weren't grandfathered in if they started the 4 months prior to the rule change.

[thenug 14]

I have United Healthcare Health Select- useless. You have to be at 40 bmi for 5 yrs, your dedutible is $5K and a lot of other nonsense. I talked to tr today and they said they will test me for a hiatial hernia. If I have that which is likely since my pcp was going to check me for it, they said they can do that surgery and do the lap band- the insurance company will pay for the hiatial hernia surgery and I will pay the rest- basically the same $5K for all with the one year follow ups/fills. HOWEVER, are they sure about this? What do I need from my insurance company to know the surgery will be covered?