Denied and Defeated..Needing Advice

[brttny88 0]

I don't usually post here but I've been coming here for several months now and absorbing all of the information I can find. Honestly, after all of that research I wasn't prepared for the phone call I had today.

I have Aetna coverage and thought that in my explanation of benefits it said something along the lines of "Weight Loss Sugery*" as being covered. Which I thought meant they will cover it if you qualify..

So after finally riding 5.10 miles in 21 minutes on my new exercise bike (a major victory for me) I got the courage to call my insurance company to find out about their requirements....but THEY WON'T COVER THE PROCEDURE AT ALL! :eek:

Now, after all of the hard work, mental preparation, and research I feel completely and utterly defeated. I don't really know where to go from here because I didn't expect this to happen.

So the advice I'm looking for is how to go about surgery when you pay cash? I really can't afford it, but my mom has offered to help me out. I am almost 20 years old and I don't want to waste another minute feeling or looking like this.

I'm not interested in going to Mexico or out of state even (no offense to those of you who have, I would just like to stay close to home). I'm in North Carolina by the way.

Any help would be appreciated.

[GaryB 0]

My advice to you, is that before you decide to pay on your own, double and triple check with Aetna. Try to call and speak to a case supervisor at Aetna to get more information about Weight Loss Surgery approval process. My surgeon sent the request to my Insurance Company, not me. Maybe your surgeon can help you... Don't give up, keep researching and fighting..... :thumbup:

[greenerpastures 0]

Agreed. You need to dig into Aetna's fine print and find out under what circumstances they DO cover. Most things are covered, they just have to be covered for persuasive reasons. In my case, I got another doctor to write a letter in support of how weight loss surgery would slow down the progression of the arthritis in my joints (a co-morbidity). The program coordinator facilitated the approval process with the insurance company. She outlined my growing joint issues and made the case that my bloodwork indicated insulin resistance and a future filled with high cholesterol and diabetes (another co-morbidity). You have to develop your facts to make the surgery a MEDICAL NECESSITY. good luck.

[SPEBSQSAlady 0]

I have Aetna and they covered my surgery in full. Possibly your employer has a rider against it? I would talk to the insurance coordinator at the dr. office and have them help you. Sometimes it is not in what you ask, but how you ask it. Do not give up. Get all the help available to you out there. One lady I work with was refused 2 months ago, and resubmitted a month later and got approved and had her surgery last week. Go for it. It can be done.

[Jodi_620 37]

If you are considering being a self-pay then go ahead and find a surgeon. Have their insurance coordinator deal with insurance...they are better trained at it. If it turns out that you have to self-pay, your surgeon should be able to give you a detailed cost breakdown. I am in Northern Virginia and the self-pay price for everything is $17,500.00. They can also offer information on financing if you want to go that route.

[brttny88 0]

Thanks for all of the advice and support guys. I'm feeling much better about things now and I'm even more determined than ever.

:thumbup:

[U_go_gurl68 0]

brttny88,

If you don't mind me asking, what are your stats? Qualifying for surgery under insurance is different than just qualifying period. There are usually strict guidelines if you are relying on insurance to cover the surgery.

My BMI was lower than 40 and I wasn't a hundred pounds overweight. I also didn't have a personal significant medical history other than achy joints. My family history on the other hand is not all that great. So, although I qualified for the surgery itself, I didn't qualify under my insurance guidelines. I went the self-pay route and even went out of town for my surgery. The surgeons in my area wouldn't even do the surgery under self-pay because I didn't meet insurance criteria.

So keep researching, but don't give up. It could be that you would be covered under your plan, you just need to do all the required things. Some have a requirement of following a physician supervised weight loss plan prior to seeking surgery and several other things.

Best wishes,

Stephanie

[aubrie 6]

I have Aetna and they covered it, but it's true, your employer may not have a rider on their group policy that covers it. But check and recheck. Aetna did this to me as well. They were ASS HOLES about it. It took me 11 months to get an approval. I had to dance through hoops like a circus animal to get mine approved. I had to have all my doctors (OB/GYN, Rhuemetologist, cardiologist, PCP as well as my Bariatric Surgeon) to write letters of support for the surgery and how it would help my health. I had to have sleep studies, dietician appointments, 6 months of supervised weight loss attempts with my PCP, psych evaluations...... It was horrible. At first I cried for weeks over being turned down. Then I just GOT MAD!!!!! don't give up just yet. FIGHT, FIGHT, FIGHT!!!! Exhaust ALL possibilities.

[brttny88 0]

After several phone calls with Aetna today, I found out they will consider surgery if I get letters from doctors saying it's medically necessary along with quoted prices from surgeons and hospitals. So there is hope.

As for my stats, I am 19. I have a BMI of 54. While I don't have any co-morbidities documented, I have been struggling with high blood pressure and hypoglycemia in the last year or so. I also have a really bad family history for heart problems, diabetes..and the list goes on. So I would think (judging by what I've read from people here) that I definitely qualify.

[U_go_gurl68 0]

After several phone calls with Aetna today, I found out they will consider surgery if I get letters from doctors saying it's medically necessary along with quoted prices from surgeons and hospitals. So there is hope.

As for my stats, I am 19. I have a BMI of 54. While I don't have any co-morbidities documented, I have been struggling with high blood pressure and hypoglycemia in the last year or so. I also have a really bad family history for heart problems, diabetes..and the list goes on. So I would think (judging by what I've read from people here) that I definitely qualify.

Sounds like you should qualify to me. They may require you to be on a supervised diet first, if you haven't, but I would think with your history and current BMI, you would definitely qualify. Good luck.

Sincerely,

Stephanie

[ocbreeze4u 0]

I have Aetna PPO and I am also a Nurse Practitioner. My BMI was 36 and I had only one Comorbidity...Diabetes. I had to go through two appeals and a peer to peer review, I handled my own appeals without the help of the surgeon's office and I won. With that said, I know Aetna VERY WELL.

First off, they told you wrong information about they need "price information", it does not matter how much it cost at the institutional care level. When you use an Aetna Provider, Aetna and the doctor have a fee schedule they use and Aetna pays no more or not less...example, Lapband surgery as billed by doctor is $18,500 however, as a provider for Aetna they will pay $11,900 so the surgeon only gets paid $11,900 and you pay any copays and coinsurance out of pocket and nothing more, the surgeon eats the difference of $7,400.

Aetna will tell you different things depending on who you talk with. If you are PPO and not HMO then you do not need a referral to a Bariatric Surgeon. Find out who is on your provider list in your area and call that office, attend their seminar. After that they will schedule a consult and at that time your doctor will find out what your insurance needs and he will handle it for you.

Aetna's qualifications are a persistant BMI 40> for two years, 6 months physician supervised diet including diet and exercise behavior modification education and monthly weigh-ins. They no longer require a psych evaluation however, your surgeon may require it. You may also qualify if your BMI is 35> with one comorbidity such as diabetes, heart disease or sleep apnea. But like I said, the surgeon you choose will walk you through this and also oversee your 6 month diet.

Good luck.

[brttny88 0]

OH wow! great!

Do you think they'd do the multidisciplinary monitored weight loss instead? This one is for 3 months and you have a low calorie diet supervised by a dietician/nutritionist, exercising supervised by profressional, and behavior modification supervised by a professional.

Thanks!

[ocbreeze4u 0]

No, they are very clear on what their requirements are and they do not deviate from them. My appeals were due to my BMI dropping to 34.8 (they require 2 years persistant BMI> 35) for only 4 days, I dropped below by ONE POUND so I was initially denied. Yes, they can deny you by one pound so I highly doubt they will accept anything less than a 6 month diet and do not miss your monthly weigh-in...they will deny you.

The only reason why I had the two appeals over turned was due to I discovered that the doctor had my height wrong in my chart, they charted 5' 7", I am only 5' 5" so that meant that my BMI never dropped below 35. I had my surgery on July 17th and I am doing well.