How To Proceed?

[searching 5]

05/15/2013

Information about insurance coverage in Washington State that I have found to date: There is no insurance coverage unless you are on medicare, You or spouse are in a group with 50 employees and WLS is added as a rider, or your a Federal employee.

If anyone knows any different please share.

Thank you,

Searching

[Bellanthin 112]

I am somewhat long winded when it comes to writing' date=' 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!![/quote']

Me I'm 217 5'2 high blood pressure high cholestral bmi 39.5 was denied also w atena did a peer to peer Thursday waiting to here I was devastated denied day before surgery

[PaNailGirl 44]

The sleep apnea is huge. Make sure you get the sleep study!