Clinical Policy up for review question...

[adagray 1]

I have Aetna and noticed that their clinical policy bulletin for obesity surgery (Obesity Surgery) is up for review on 2/12/2009. Not that far off. Should I be worried that they will change it against my favor. I have my BIG appointment w/the bariatric surgeon's office this Friday (2/6). Should I push to get all my paperwork together and submitted ASAP? I still have the physician supervised diet to complete, but Aetna will approve pending the completion of this diet if you submit prior to completing it. What do you think?

[RestlessMonkey 7]

I'd submit it NOW. If they become more lenient you can't lose, and if they get worse, then you'll be glad you rushed it.

[oyesican 0]

Hi Ada - That's interesting, I also have aetna, 35 BMI and 3 co-morbidities, BUT since I was a good dieter and lost weight I haven't had a BMI of 35+ for 2 years. I might have to spend another 18 mos at this weight, which I hate. diabetes, sleep apnea, hypertension...I'm so ready NOW. Have you heard any more about your approval submission? I'm on my second appeal but so far no luck.

[adagray 1]

Hi Ada - That's interesting, I also have aetna, 35 BMI and 3 co-morbidities, BUT since I was a good dieter and lost weight I haven't had a BMI of 35+ for 2 years. I might have to spend another 18 mos at this weight, which I hate. diabetes, sleep apnea, hypertension...I'm so ready NOW. Have you heard any more about your approval submission? I'm on my second appeal but so far no luck.

I'm glad to have found someone who is in a similar situation as mine. Just out of curiosity, do you have documented BMIs of 35+ going back past two years? I'm going to try to submit those to help my case. I expect I'll end up being denied as you were, though, but will appeal. Worst case, I will stay this BMI for however long I need to be approved. I'm certainly not gonna diet again just to put it back on. I'm done w/yoyoing.

Anyway, back to your question, I haven't submitted yet. I just didn't get all my paperwork together in time and still have some additional tests to take care of that the surgeon's office ordered last Friday. So, it may be another couple weeks before I submit. Hope that the clinical policy does not change for the worse in the meantime. Interesting thing is that when I went for the psych eval, the therapist said that a lot of the insurance companies are dropping the 6 month diet rqmt because it really should not be necessary if you have documented history of dieting already. So, who knows, maybe Aetna will loosen up their policy. A girl can hope! LOL

[oyesican 0]

No, two years ago I dieted down to a BMI of 31, so that is in my records and that is what they are using against me. I have been over 35 prior to the past 2 years but they are looking at the fact that I was at 31 within their 2 year time frame. As I understand it, the National Institute of Health sets the guidelines and has no time restriction - that is purely ins company *stuff*. Hopefully their review will remove this unneccesary restriction. I have appealed through obesitylaw.com and I am on my second appeal. I should know something in another 30 days on this appeal - I'll keep you posted. The thought of staying at this weight with these health issues any longer is really upsetting to me.

[MacMadame 81]

The thought of staying at this weight with these health issues any longer is really upsetting to me.

IMO making people do this is medical malpractice. I hope someone takes on these insurance companies and makes them start treating us better.

[oyesican 0]

WOOO HOOOOO

I got the fax today - after an independent review decision, aetna is going to have to reverse their denial and approve my surgery! I hope to be scheduled in the next few weeks! Obesitylaw.com handled the appeal at no cost to me.

It's going to be a fabulous 2009 after all!

"Oh Yes I Can!"

[adagray 1]

WOOO HOOOOO

I got the fax today - after an independent review decision, aetna is going to have to reverse their denial and approve my surgery! I hope to be scheduled in the next few weeks! Obesitylaw.com handled the appeal at no cost to me.

It's going to be a fabulous 2009 after all!

"Oh Yes I Can!"

Thank you SO MUCH for your update. I'm so happy for you and happy for me too because this means I should be able to eventually get approved even if it takes many appeals. I haven't even submitted to insurance yet. I'm still getting some stuff together. Will probably submit in about one week after getting results from my sleep study back.

[oyesican 0]

Thanks! It took a while - since August, and 2 appeals but my surgery date is now March 9th. I am soo looking forward to better health!