Approval Problems

[vincereautmori 323]

I tried this in another forum and got no responses, this looks more appropriate. This is a question for a friend who saw my success and began his own journey through weight loss surgery. Has anyone else had problems being approved by the insurance company (Aetna)? He was required to have all the tests done and to attend 6 months of supervised diet with a nutritionist, he's done all but with a big problem, he gained weight during the six months. I had been telling him it might be best to begin getting his head into it, I was cutting back on fats and carbs three months before my surgery, so I was in full swing by the time I was recovering. He's morbidly obese and has co-morbidities, so an excellent candidate except getting control of his eating. His PCP has spoken to the insurance company, and they still rejected him, now he's persuing a formal complaint. Can he appeal? Has anyone had any luck fighting them? I don't know what else to offer in advice, hope someone else can.

[Sharon1964 2,530]

He needs to get a copy of their policy regarding weight loss surgery. If it doesn't say he must stay the same or lose weight during the nutrition portion, then he should be able to successfully appeal. In that case, it would be the insurance company's doctor's OPINION to deny, and he is not following the written policy.

[twittymilk 51]

Here is the link to Aetna Clinical Policy Bulletin on WLS.

You cannot have a net weight gain

http://www.aetna.com/cpb/medical/data/100_199/0157.html

[KSTUZ 438]

I had a NET GAIN, during my 3 month required nut visits.

I had a lot going on suddenly at that time in my life, that lead to severe stress and emotional eating.

ANYWAY, I appealed the first denial, and continued to keep NUT appts each month.

I made sure I did not have another net gain.

Yet my first appeal was denied.

I then hired Lindstrom Obesity Advocacy to fight for my second level appeal.

They told me because I had a bmi of 47 and more than 2 comorbitities,

They believed they could overturn Aetna's decision.

It was NOT guaranteed, but the Lindstroms assured me they would not take a case unless they felt they had a chance to win.

After my level two appeal was submitted by Mr. Lindstom himself, 2-3 weeks later...

I WAS APPROVED!!

I was sleeved 1/5/15

Best thing I've ever done!

Don't give up!

[m_kuiphoff 1]

How much did Mr. Lindstrom charge you ?

[KSTUZ 438]

How much did Mr. Lindstrom charge you ?

Call Kelley

They have different prices...

But it was worth every penny.

I am 8 months post sleeve

[KSTUZ 438]

http://wlsappeals.com/2142/walters_bariatric_surgery_blog/gained-weight-pre-op-diet-now-what/

[Dream4tc 192]

Check with Lindstrom patient advocacy. They help with WLS appeals http://wlsappeals.com/

[m_kuiphoff 1]

Thank you