Newbie Looking for Help w/Aetna Insurance

graceland630 · December 28, 2008

Hi everyone!

My name is Christi and I am a complete newbie to this site - this is my first post. I have been going to an endocrinologist for nearly 6 months, and my weekly appointments include consultations with a dietician, physical therapist, and psychologist. I have not had success so far, and my doctor has suggested lap band surgery as a tool for my weight loss.

At first, I struggled with a sense of failure at having to turn to surgery in order to succeed at weight loss, but when I finally realized that it was a TOOL and not 'giving up,' I found out that our insurance doesn't include lap band surgery. I received the following from the HR lady at my husband's employer:

"I understand your frustration and concern but, as I previously stated Lap Band surgery is not a covered benefit under our plan. Unfortunately there is no one at the insurance company that would tell you otherwise. I would suggest that you have your doctor intervene on your behalf and ask them to appeal directly to the insurance company regarding the matter and while I cannot guarantee the outcome, it may be worth a try."

Can the insurance company change the benefit based on input from the physician? Has anyone had success this way? If it makes a difference, we live in Indianapolis, Indiana, and our insurance is through Aetna. I could really use some help, as this is completely unchartered territory for me!

Thank you, and I look forward to talking with all of you!!

Christi

amberd910 · December 28, 2008

You need to call your insurance company directly and ask them if it's a covered benefit but if your husbands HR dept says it's not then most likely they did not purchase the ryder to the policy. If it's not there is not much you can usualy do. I know with my primary insurance company my work would actully have to purchase the policy ryder to include gastric bypass & gastric banding (lapband) but they chose not to (small company). I have heard of some attorneys being able to get approvals but those can take months and dont forget the cost involved. Best of luck to you!

oyesican · December 29, 2008

You may want to try obesitylaw.com. They are legal advocates that will review your case and if it's possible they can help you, they will tell you. They are appealling Aetna for me. It will most likely take quite a while but it can't hurt to ask.

Good Luck to you!

graceland630 · December 29, 2008

Thank you so much for the quick replies! I will call Aetna first thing in the morning and find out where I stand and where I need to go from here. I was just so excited that I had made the decision - then, to find out that it wasn't covered was just heartbreaking!! I'm hoping if the HR lady thinks there could be some appeal process, that there will be and that it will be successful. I know that if it's meant to be, the good Lord will provide! ) Happy Holidays, Everyone!!

amberd910 · December 29, 2008

Thank you so much for the quick replies! I will call Aetna first thing in the morning and find out where I stand and where I need to go from here. I was just so excited that I had made the decision - then, to find out that it wasn't covered was just heartbreaking!! I'm hoping if the HR lady thinks there could be some appeal process, that there will be and that it will be successful. I know that if it's meant to be, the good Lord will provide! ) Happy Holidays, Everyone!!

At one point I actully looked into private insurance (not going thru my work) and seeing if any policys had coverage. I knew I would pay more, right now, for coverage for insurance, but the procedure would be covered. I think United Healthcare has a ryder you can purchase to their policies. Also, if you are eligable for Medicaid (state insurance) many plans in many states also have the surgery an option (that is how mine was covered, via secondary state insurance). Best of luck to you. I know what you are going thru becuase I was approved in June when I started the program but in November insurance denied EVERYTHING and denied the appeal. I ended up switching my medicaid and was approved in 48 hours. It's amazing how some of these dr's at insurance companies decide to play "God" with people's lives.