How To Proceed?

[jmomma5 0]

I am somewhat long winded when it comes to writing, so I will attempt to be brief! Sorry in advance if I end up with a long post! Anyway, I have been on this journey now for almost a year and a half! I began in November of 2010! At the time, we had Anthem bcbs. I went to the wls orientation and met with the dr. to find out if I was even a candidate for this type of surgery since my BMI is not 40. I am about 215 lbs and 5'3" so my bmi is about 38. I have several comorbidities, includig high bp, GERD, arthritis in hips an knees, and high cholesterol. He determined that I was a candidate, so I called Anthem and was told by a rep that yes, insurance covered the surgery so I proceeded to jump through the necessary hoops! When we submitted the request for approval, it was denied. My husband's company had specifically excluded wls from its policy! Remember though that I had been specifically told by a real person that I was covered? Well she wrote in her notes regarding our conversation that she had told me that it wasn't covered! I was vindicated by the transcripts of our recorded conversation which proved that I had been given incorrect information and she had falsified her notes! Unfortunately, while at least I had proof that I had indeed been given the wrong info, because I hadn't already had the surgery, I was pretty much S.O.L! If I had had the surgery they would have been forced to cover it! I tell you this to give a little background. Needless to say, I was devastated, heart broken, depressed, etc, etc! I had no recourse! They weren't going to suddenly cover this, I couldn't afford a legal fight, (although I think I had a case!), and I certainly couldn't afford a $20K surgery out of pocket!

Fast forward a year! My husband took a new position with a new company that had Aetna and does cover wls!!! Yay! I wasted no time! I was back in the dr's office about an hour and a half after he signed his contract! The dr's determined that I would qualify, but I had to complete a 14 wk medically supervised weight loss class. A pain, but whatever I had to do, I was wiling to do! Mind you, I had to be careful, because I couldn't drop below a bmi of 35! Done! Woo hoo! All paperwork submitted! And then the news that once again. I had been denied! WHAT?! Apparently, since my high bp is controlled on medication they deemed it not medically necessary! Are you freakin kidding me?! No mention of the GERD, the high cholesterol, the hiatal hernia, borderline diabetes! So now I appeal! I am waiting for more information re: my medical history, and with any luck a letter from my pcp supporting the medical necessity of the surgery! But meanwhile, I am again deflated, discouraged, angry, and depressed! I am thinking that I should do a sleep study to see if sleep apnea is a factor, which I suspect it is, so that I can add that to the list of comorbids!

So, sorry to be so long, but I did warn you! If anyone made it this far, here are my questions! Is anyone with a bmi under 40 trying to get approved/ been approved with Aetna? If so, what are your comorbidities? Just trying to weigh my odds of the surgery being approved upon appeal and looking for a little hope to keep me going! Thanks for your responses, if you made it this far!!

[GivingItMyAll 168]

I am jumping through all of the hoops now, waiting to see the surgeon, the phychologist, and the nutritionist. I am praying that I get approved. Good luck to you on your journey. Keep us updated.

[jwade77 0]

I have United Healthcare and I have a BMI under 40. I jumped through all the hoops, found out I had sleep apnea. My surgeon submitted everything...DENIED. Had a peer to peer and UHC upheld their decision. So now, my Dr. is appealing. I feel exactly the same way you do....depressed, angry...etc. I plan to appeal to the end of the earth. I am not going to give up and you shouldn't either! Keep your chin up.

[StephanieRN 2]

I have AETNA and they denied me for the same exact reason as you. My BMI is 39 and I have high blood pressure which they said was controlled on medication (even though it was running high 130's/ 90-97!!! My coordinator said it is ridiculous that I was even denied the first time. Now I am in the appeals process which she told me they have 30 days to give an answer. How did yours turn out? Did you ever get approved?

[jmomma5 0]

I have United Healthcare and I have a BMI under 40. I jumped through all the hoops, found out I had sleep apnea. My surgeon submitted everything...DENIED. Had a peer to peer and UHC upheld their decision. So now, my Dr. is appealing. I feel exactly the same way you do....depressed, angry...etc. I plan to appeal to the end of the earth. I am not going to give up and you shouldn't either! Keep your chin up.

I am so sorry! I totally understand what you are going through. I am surprised that with sleep apnea you were denied! That bums me out as I was hoping that my "mild" sleep apnea might score me some points in my appeal! Hopefully we will both be successful eventually!

[jmomma5 0]

I have AETNA and they denied me for the same exact reason as you. My BMI is 39 and I have high blood pressure which they said was controlled on medication (even though it was running high 130's/ 90-97!!! My coordinator said it is ridiculous that I was even denied the first time. Now I am in the appeals process which she told me they have 30 days to give an answer. How did yours turn out? Did you ever get approved?

I am about to submit my appeal! I gathered as much history as I could re: my other comorbids like GERD, arthritis. High cholesterol, and high triglycerides, mild sleep apnea, as well as a letter from my primary care physician supporting my decision. I also wrote an impassioned letter pleading my case an asking that they consider all my obesity related medical problems not just high blood pressure! I also asked them to view me as a person, not just a medical case file! I will submit everything tomorrow so we'll see how it goes! I will be praying hard and keeping my fingers crossed! I will let you know as soon as I hear anything! Keep me posted on your fight as well!

[Bypassjourney 88]

I have aetna. My BMI was less than 40. I had the weight history for two years that was required. I got the sleep study and had mild sleep apnea. That is the only co-morbidity that I had. I was approved after the 12 week nutrition, etc. Read through their clinical plan description (I think that is what it is called) and read all the fine print. I read and re-read that 38 page document multiple times so I would know every little possible thing they needed or required.

Good luck with your appeal. Keep at it. It is SO worth it!

[vegasrn27 1]

I have aetna. My BMI was less than 40. I had the weight history for two years that was required. I got the sleep study and had mild sleep apnea. That is the only co-morbidity that I had. I was approved after the 12 week nutrition' date=' etc. Read through their clinical plan description (I think that is what it is called) and read all the fine print. I read and re-read that 38 page document multiple times so I would know every little possible thing they needed or required.

Good luck with your appeal. Keep at it. It is SO worth it![/quote']

Re: your "mild sleep apnea", did Aetna require you to get a CPAP machine? I am going to a 2nd sleep study...not sure why, but I do know my PCP is trying to get me comorbidity. BMI is 37 and she even suggested that I try to gain weight so my insurance would pay. Not going to do that.

[jmomma5 0]

Re: your "mild sleep apnea", did Aetna require you to get a CPAP machine? I am going to a 2nd sleep study...not sure why, but I do know my PCP is trying to get me comorbidity. BMI is 37 and she even suggested that I try to gain weight so my insurance would pay. Not going to do that.

[jmomma5 0]

I did not get a cpap machine and they would not approve me, despite my long list of comorbidities. Because of my BMI being under 40 (37) they refused based on my high blood pressure being controlled on two medications. According to their clinical bulletin it has to be uncontrolled on three medications! In my opinion a completely ridiculous requirement! I have "mild sleep apnea" and that was not even considered. The only basis for their denial was the HBP. I appealed once and submitted tons of info on history of hypertension, arthritis, sleep apnea, GERD, high cholesterol, etc, and was denied again. I decided to give up at that point because in order to appeal again, I needed to add additional documentation and I had submitted everything I had. So frustrating! I'm open to ideas if anyone has any! I hope you get approved! If sleep apnea is your only comorbidity and you are approved, I may try to take my appeal to the next level. Who knows! Maybe the third time will be the charm!

[vegasrn27 1]

I am ready for the self-pay option if this doesn't work. I am not willing to go thru gaining wt, just to TRY to get approved. We'll see. I am mentally ready and in the process of getting financially ready. If insurance approves me, that will just give me a little extra $$ for a mini vacation

[jmomma5 0]

I hope you get approved and can enjoy a new body and a fun vacation! Keep me posted on whether you get approved! I had just given up, but after reading all these posts, I think I will resurect the fight and try again! I decided after responding to your post and reading some others to try going through a different weight loss program to see if they might be of more help to me. The surgical coordinator I was working with at the other clinic was really no help at all and usually made me feel like I was kind of an inconvenience when I would call to ask questions about what to do next! I'll see what this other place has to say and if they have any suggestions as to how to proceed! It just makes no sense that I was denied when I'm reading all these posts about people who have the same BMI, only one comorbidity, without HBP, and they get approved quickly without any issues from Aetna!

[vegasrn27 1]

My insurance coordinator has been very helpful and is knowledgeable about how to get insurance authorization. She sent me an email the same day of appt and responds almost immediately to email inquires I have sent. It's making the process a lot easier, which as I have seen from most the posts, is stressful enough already. Good luck to you! I will hopefully have answers in the next 2 wks.

[jmomma5 0]

Never got approved. I was denied on my second appeal and my surgical coordinator said that since I had submitted all my information and had nothing new to submit, it would be useless to appeal any further. Depressed angry and hope was gone.

Fast forward again! My husband has left that job, is now self employed and our insurance will likely be an HSA qualifying bcbs plan. As soon as we have our policy confirmed, I want to try to move forward again with surgery! Anyone have something like this and has your surgery been covered!

[Kyle Lynn 4]

I am so sorry! I totally understand what you are going through. I am surprised that with sleep apnea you were denied! That bums me out as I was hoping that my "mild" sleep apnea might score me some points in my appeal! Hopefully we will both be successful eventually!

I work for Uhc. I know it seems like it is uhc's fault however it is your employer that choose not to have that covered you might want to try to speak to them. Uhc only admins the benefits. If you have any questions I'm always here to help. By the way Uhc DOES NOT cover this surgery for me. I had to pick up a secondary insurance through my husbands work that would cover it.