Insurance - denied...

[redmtn 0]

After jumping through all the hoops this summer and spending a substantial amount of money, my insurance has denied my request for revision to sleeve. Reason: "excludes gastric sleeve procedure and , therefore, it is not covered benefit under your Presbyterian benefit plan." I don't really understand why they didn't tell me this in the first place. they would just say "we have to get the info from your doctor, then we decide". Anyone have any experience with this? I'm so disappointed. I was hoping for Christmas surgery date.

Thanks all!

[kellyw74 258]

Wow! I am so sorry. Does your plan say that they do not pay for the sleeve? It would seem that you should have been informed of that in the first place!

WOW!

Kelly

[happy1957 138]

I feel your pain, I too was denied by Aetna this month. They pay for the sleeve under my plan, but it's because I had dieted in 2009 and was below the 40 BMI I needed to prove for 24 consecutive months. Although my weight was clearly above the 40 BMI in 2008, partially 2010 and currently. Will your plan for RNY? Have you given that thought? I am sick thinking I have to remain this weight for a few more months to pacify their needs when they have 23 years of weight records that clearly show my roller coaster weight history of cycle dieting. It is disheartening. They are hoping you will just go away, but don't give up. Write a nice letter of appeal, being heard but not over bearing. You never know what could happen. I wish you the best of luck!

[lml32937 65]

If your plan "excludes" it then your employer elected to not have coverage for that service. It is not the insurance- it is the particular plan you have. Normally though if you have a doctor willing to fight and there is enough medical justification you may be able to fight that. otherwise for "excluded" benefits you are SOL... sorry... Now as to why they didn't tell you earlier- perhaps someone called to verify your benefits and was told that records would need to be received before they made a decision because perhaps Lap Band or RNY is (a lot of plans cover these) and your doctor thinking of what is normally pre-requisites so to speak went ahead and did all of them and when all is said and done once they saw revision it was not covered. Will they pay for the band to be removed?? Have you had problems with your band??

[longer-life 139]

I feel your pain, I too was denied by Aetna this month. They pay for the sleeve under my plan, but it's because I had dieted in 2009 and was below the 40 BMI I needed to prove for 24 consecutive months. Although my weight was clearly above the 40 BMI in 2008, partially 2010 and currently.

I also have Aetna and would have been in exactly your situation had I not been diagnosed with sleep apnea about a month ago. Did you provide weight proof of 2007 and proof of dieting in 2009 (like Weight Watchers or gym receipts)? I would hope this and a peer to peer from your surgeon would do the trick or else they are punishing you for trying to lose weight.

Try posting a thread about this. I can't imagine you are the only one that has gone through this. Best wishes.

[Wheetsin 714]

There are twp types of exclusions (well, for the sake of this conversation there are.)

Plan enforced - meaning your insurance company does not cover the service, ever.

Employer-enforced - meaning your employer, when piecing together the coverage they wanted to offer employees, did not elect to have the service included.

The verbiage aboves sounds like the latter: employer-enforced.

What "they" are you referring to in your question: your insurance company, or your surgeon's office?

If you're referring to your insurance company, it depends. Did you ever ask them if the procedure was covered? Did you ever ask them the requirements? And if so, what did they tell you? If you're referring to your surgeon's office, eligibility should have been determined before anything was scheduled. Normally surgeons require your pre-approval to be received before they will begin setting up your pre-op appointments.