Help please, lack of history

[PlannerGirl 3]

I am very ashamed to even admit this, but I haven't been to a doctor in the last couple of years before getting involved in the pre-surgery programs. Unfortunately, I don't have the history Aetna requires. My BMI currently is just over 50. Now any reasonable person would know this didn't happen in the last week and a half.....but we are dealing with insurance, so reasonable may be unrealistic.

I'm working on some alternatives. I can get a medical record from 2005 and I will send that. I also am putting together a series of pictures where I can hopefully print the time stamp with it. I'm thinking about asking one of the trainers from the gym who has become a close personal friend to write a letter stating that the weight has been an issue for the past two years.

Has anyone else had this dilemma, and what worked. I would appreciate the input.

Thanks!

[Donna4545 13]

It sounds like you're doing all the right things. Who is your ins co and what are their requirements? Your BMI alone should get you approved at most places.

[PlannerGirl 3]

My insurance is Aetna, through my husband at American Airlines. The doc's insurance submission person told me she had someone else from Aetna declined for lack of history (apparently insurance companies will use anything they can to decline). That person used an obesity attorney who apparently has 100% success and it worked. I hope to avoid that by adding the pictures and older documenation. We'll see.

[6kiddos 18]

hmm. I have the same issue. I have 2008 and 2010 but NO 2009. I am going to the gym and asking for the record they have from me during 2009 (I was weighed monthly for 4 months there). I am hoping that and 1-2 pictures will work ok. I have 1 dr. visit in 2008 showing my weight....I hope it works.

[settebee 11]

Hey! I'm in the same boat as you guys! I too was lacking weight records. I had weights from 07 and 08, and I was denied just yesterday. My BMI is too higher than 50 and still that wasn't good enough. I went to my gym and had the manager type me a letter with my starting weight from August of 09. I hope it works! Just be sure if you have documents from your gym that it's typed in their letterhead! Good luck! I know it's frustrating. My appeal will take up to 30 days with Aetna! Wish me luck! :001_smile:

[PlannerGirl 3]

I am so sorry to read you got denied. I think it's unconscionable to deny a person with that high of a BMI simply because you don't have the medical records from one of the last two years. Clearly that weight wasn't attained in the last week and a half and Aetna is exercising a loophole hoping you'll give up and go away.

Please keep me up to date on your appeal. I'll be sending good thoughts your way.

[mrspalmour 0]

Wow guys,

These stories break my heart. I work for UnitedHealthcare and I process appeals for pre service services. Many of which are obesity surgeries. I have had to process denials for people I know clearly were obese in those years however most plans especially for large companies are administrative services only. This means that the insurance company does not actually pay the claim the employer does. The employer sets up their benefits with the insurance company. As far as obesity surgery goes they can choose to exclude it all together or set up criteria a member must to get the surgery covered. I have seen plans that all a member has to have is bmi over 35 to plans that have such strict criteria its almost impossible to ever get the surgery. The point is if its written in your Summary Plan Description the insurance company does not have descretion to deviat from it. Its not their money they are playing with. If the medical criteria is not submitted it does not even see a doctor for review it is just excluded. I know its horrible and sad. I have had so so many people I want to approve but just cant. Anyway the best way around this is to bug your HR department to reach out to their account manager and get the inside person to tell the insurance company they want to make a benefit exception. Look into your plan and see who they have set up to do their appeals. Some employers do their own appeals and can make plan exceptons there. Other than that sometimes there is just nothing that can be done to sway the decision. Simple answer if its in plain black and white as criteria that must be met to be eligible for coverage you must have the documentation to get coverage no matter how logical or illogical it is. I wish there was a better way.

As I said I have had to deny these myself and as bad as I want it I feel horrable denying people I know are suffering as I am however these people I was deying had the option for covereage and I didnt untill my husband got a job with a company that covered it.....YAY.... I have been waiting for years.

Michelle

[settebee 11]

Michelle,

Thanks for the inside, but make sure I have this right. You recommend I contact my HR dept and ask to speal to benefits who handles the the insurance claims and ask them if they could over approve my appeal?

Thanks for your help in advance.

Suzette

[settebee 11]

Michelle,

P.S. Congrats on being able to get your sleeve!! :biggrin2:

[PlannerGirl 3]

Thanks Michelle for the inside information, depressing as it may be. I plan on providing as compelling a case as possible, but I am starting to lose hope. My doctor's office has told me of a lawyer in CA who has a 100% win ratio in getting these things overturned should I be denied. I was thinking about putting in my initial letter something like......"after consultation with an obesity attorney....." Do you think the insurance company will be at all swayed by this. I plan to be tenacious, and I have no problem letting them know that. As I sometimes tell my husband, we can do this the hard way or the easy way, you choose.

Thanks again for your insight.

PS Michelle, I just noticed you live in McKinney. I'm in Dallas. Have you had your surgery yet? Who did or are you using. Feel free to private message me if you don't want to blast that info to everyone.

Edited August 30, 2010 by PlannerGirl