Seeking A Dr That Will Fight Aetna - Aetna Says Surgery Excluded - But It Is Medically Necessary

[th186607@gmail.com 1]

I am seeking a new doctor that is willing to fight my insurance for the sake of the their patient (ME).

I have been going thru 7 months of dr. appts, guided and recorded diet for 6 months, 6 months of dietician appt., 2 sleep studies, cardiologist, a psychologist, and we had United Health Care and they gave all the requirements for consideration and I met all those. At finalizing all of it, my husband's job changes their insurance to Aetna POS II and they are saying that Bariatric is excluded. I was told that I needed to have dr. office submit a "medically necessary" with all the clinicals and they would put it thru their medical team. Well, it was just said (on telephone and not received letter of denial yet) that it is excluded. That they will remove a band or fix a current bariatric surgery issue. I have had the lapband and had it removed in 2009. Worst 6 yrs ever! Throwing up all the time. I have had a plication. I WANT THE SLEEVE. Lets SAY IT THIS WAY, i NEED THE SLEEVE!!!!!

I WANT A DOCTOR (and apparently mine isn't a fighter) that will fight for this with me!!!! After all, what did they take their oath for? Preserve Health of people. Oath, one is

"I will prevent disease whenever I can, for prevention is preferable to cure"

I have a disease, OBESITY Morbid! I have SEVERE OBSTRUCTIVE SLEEP APNEA, high blood pressure. I am a perfect canidate for this.

I just need a doctor that is willing to go the mile with me and FOR me!

Is there such a doctor?

my current doctor (or should I say his office staff) does not seem like they are concerned with

getting this thru. They were all eager in the beginning and now there needs to be a push with the insurance - they are hardly returning my calls, and says I need to contact my HR Dept.(which I have - waiting on a call to be returned from them). I am ready for this. I need this.

[th186607@gmail.com 1]

my current doctor (or should I say his office staff) does not seem like they are concerned with

getting this thru. They were all eager in the beginning and now there needs to be a push with the insurance - they are hardly returning my calls, and says I need to contact my HR Dept.(which I have - waiting on a call to be returned from them). I am ready for this. I need this.

[Izuri 428]

i don't know of very many doctors, but I do want to wish you luck. I know that I had called aetna when I thought it was going to be the insurance my family would be switching to, and their requirements are pretty strict. I was also told at the time that the employer is the one who chooses whether or not to include bariatric surgery. I don't know how true or untrue that is, but that might be part of the issue. (((((HUG))))) I'm sorry they are being such a PITA, I really do hope things work out for ya.

[KS Fort Worth 86]

I would suggest you contact Dr. David Kim or Dr. Wade Barker. They are both in the DFW area and do a LOT of these, so their people are very experienced at dealing with insurance. (I chose Dr. Kim but did one consult with Dr. Barker, and have nothing against their practice.) There are several other bariatric surgeons in the Metroplex who also do a large volume. I have Aetna and had no problems, but I do know that the same company can have different policies with different employers. The insurance experts at one of these surgeon's office can help you wade through the "jungle." If you've already done a lot of the prepwork, you have a RIGHT to copies of everything you've had done, sleep studies, blood work etc. Could save everybody some time. You should also be able to get a copy of your health insurance policy from either Aetna or your husband's company. Sometimes, Insurance companies play games and will deny something just to see if you will go away, and approve it on resubmittal.

Good luck, and don't give up!

[isajck 229]

In all honestly, your problem is with the employer in question not the doctors office. If a procedure is explicitly excluded as a benefit it is because the employer decided this. The truth of the matter is an insurance company only writes policies based on what the employer will cover/pay for. Your doctor's office was helpful in the beginning because you had a health plan that covered the procedure, now that has changed and nothing they do will change such an explicit exclusion, medically necessary or not, if that is how the plan is worded.

[iggychic 1,405]

Well that's not entirely true (that employer decides all benefits). State and federal law are involved as well. In Washington the surgery must be approved with co morbidity issues and coverage for lower bmi obesity is difficult but possible from policy to policy In Alaska our policies are required to cover with comorbidity but we can deny up front if there are none. (choose not to cover under elective/cosmetic clause). My employer, who is me, does not cover for the second but has to for the first. It just wasn't something that came up in the negotiations so we missed it. Next year both will be covered! But in all honesty, if it's not covered, it's not covered. The only fight is to verify state law and then use your diagnosises with the law in hand to point out the error of the companies ways if they have denied Inappropriately. This becomes your battle, not the doctors office.

Look to your policy for the appeals process once you have verified there is any coverage via your plan documents. If there isn't coverage though....there just isn't. You can go to the employer and ask them to add it in a future renewal period, but that's all you can do really. I couldn't change my policy and add it to cover me. They can't either if it's excluded.

[isajck 229]

Well that's not entirely true (that employer decides all benefits). State and federal law are involved as well. In Washington the surgery must be approved with co morbidity issues and coverage for lower bmi obesity is difficult but possible from policy to policy In Alaska our policies are required to cover with comorbidity but we can deny up front if there are none. (choose not to cover under elective/cosmetic clause). My employer, who is me, does not cover for the second but has to for the first. It just wasn't something that came up in the negotiations so we missed it. Next year both will be covered! But in all honesty, if it's not covered, it's not covered. The only fight is to verify state law and then use your diagnosises with the law in hand to point out the error of the companies ways if they have denied Inappropriately. This becomes your battle, not the doctors office.

While it is true that the state/feds can require certain coverages, if the OP was in a situation where such mandates were in place I doubt she would have received the denial to begin with which is why I did not mention this. I know at my place of employment, we do not cross state/federal mandates lightly (no one wants an ugly, unnecessary fine) so rules are built into our system in an attempt to ensure it does not happen.

[th186607@gmail.com 1]

Update of my fight with this.

The doctor's office did say that I had to fight with the insurance company. The HR guy at the employer where my husband works has stated that the policy was to be "identical" and go "hand in hand" with what was covered by UHC in the previous coverage policy. Aetna says "no it is excluded" that the HR Dept can permit them to make an exception and include this for me. Also, they said that the UHC still can extend the coverage to cover this, if HR says it's ok. So I have no idea. I don't want to get my hopes up to get shot down. But I want and need this very much. I have severe obstructive sleep apnea, high blood pressure, and a bmi of 40, also my EKG came back bad. Seen a cardiologist and he says the weights got to go.

I am 5'5" at 247# and have had this issue for 30+ yrs. with the weight.

I am keeping in direct contact with the HR guy. I just don't want to seem like a pain in the ass, cause I don't want him blowing me off. I want him to work and get this passed.

Any suggestions please pass my way! I am desperate to get this.

Thanks ya!

Theresa

[1920-Zeta 64]

I am seeking a new doctor that is willing to fight my insurance for the sake of the their patient (ME).

I have been going thru 7 months of dr. appts' date=' guided and recorded diet for 6 months, 6 months of dietician appt., 2 sleep studies, cardiologist, a psychologist, and we had United Health Care and they gave all the requirements for consideration and I met all those. At finalizing all of it, my husband's job changes their insurance to Aetna POS II and they are saying that Bariatric is excluded. I was told that I needed to have dr. office submit a "medically necessary" with all the clinicals and they would put it thru their medical team. Well, it was just said (on telephone and not received letter of denial yet) that it is excluded. That they will remove a band or fix a current bariatric surgery issue. I have had the lapband and had it removed in 2009. Worst 6 yrs ever! Throwing up all the time. I have had a plication. I WANT THE SLEEVE. Lets SAY IT THIS WAY, i NEED THE SLEEVE!!!!!

I WANT A DOCTOR (and apparently mine isn't a fighter) that will fight for this with me!!!! After all, what did they take their oath for? Preserve Health of people. Oath, one is

"I will prevent disease whenever I can, for prevention is preferable to cure"

I have a disease, OBESITY Morbid! I have SEVERE OBSTRUCTIVE sleep APNEA, high blood pressure. I am a perfect canidate for this.

I just need a doctor that is willing to go the mile with me and FOR me!

Is there such a doctor?

my current doctor (or should I say his office staff) does not seem like they are concerned with

getting this thru. They were all eager in the beginning and now there needs to be a push with the insurance - they are hardly returning my calls, and says I need to contact my HR Dept.(which I have - waiting on a call to be returned from them). I am ready for this. I need this. [/quote']

Dr. Castro is really good. He is my doctor. He is off wheatland in dallas.

"GOD IS WORKING ON YOUR BEHALF ,SO Keep having faith."<br />Your Sleeve Buddy <br />Zeta<br />

[Bmarion662 76]

I have aetna POSII as well and mine says it is covered. I know it does because severa people at my work have had bypass and band. Must be the employers choice they may be self funded which means they let aetna manage but the nedical bills get paid by the employer

[buplee 556]

I feel you pain.

I have also Aetna POS and they denied me last week, and I work for a major insurance company that covers the employees for everything. I went through my required three months of nutrition counseling and then it took me three months to get my other clearances. The reason for my rejection was I was out of coverage with the nutritionist ( I should have had three more continued nutrition records, and they had no weight history from 2008-2012 ( a call to my primary care doctor could have solved that), no other comorbities ( no high blood pressure, high cholesterol, diabetes). I only had a total knee replacement and other joint issues all weight related- go figure.

The insurance specialist at the surgeon's office was livid when Aetna denied me and had a rather heated call with the team. I have now completed another two of three nutrition counseling appointments and my weight history has now been provided to Aetna. The insurance specialist thinks I should be able to get approved this time, but just in case I am going to do a sleep study to check for sleep apnea.

I have a tenacious wife, very supportive doctors, and an aggressive insurance specialist working on my behalf. I am keeping my finger crossed that I'll be approved and will get the sleeve in October.

Good luck to you on you fight with Aetna and journey. I hope you find someone to fight hard for you.