ANY HELP? - Im lost now

Post Date: 3/26/08 2:06 pm
I told myself not to get excited about this until it was over and now I am devastated......I am schedule for my RNY in 10 days and I got the call today that my insurance does not cover any WLS. I called Aetna almost a year ago and asked over and over to make sure I was covered. I gave them the medical codes and everything and they told me yes and gave me the criteria for the surgery. I have spent the last 9 months getting all of the consults and tests and NOW that it is less than two weeks from surgery my Dr's office called and said that Aetna said it is not part of my policy. Actually first they told them no and then they called a different dept at Aetna and they said yes it was covered and told them to fax everything over and them another higher up told them that the other people were wrong and that it is a common mistake by customer service people. Shouldn't they know what they are talking about when you give them your policy number and group info........WHAT CAN I DO NOW? DO I HAVE ANY OPTIONS WITH FIGHTING THIS?

I just found my exclusions on my employers handbook for Aetna and this is all it says now...... Exclusions

Treatment of weight loss when another underlying severe medical condition is not present; outpatient prescriptions are NOT covered even when there is an underlying medical condition.  I have sleep apnea and Asthma ...both linked with weight ( on CPAP) and both my parents have heart disease. Don't you think this would qualify me according to this wording?

You need to find out from your HR department if they have an exclusion in the policy - and now that Aetna has denied it once you have to find out what their appeal process is - I'm so sorry you have to go through this - I hope you win this fight - don't give up!

Best of luck to you!

Here is what I would do....take a deep breath and relax...you can pull this all together.   It seems, based on your description, that it is covered.  Call them - ask to talk to a supervisor, then ask to talk to their supervisor....don't take no for an answer.  Contact the State of CT Insurance Department.  Send them the exclusion statement and your official denial - i am assuming your dr must have something in writing, correct?  The Ins. Dept will tell you if you have a leg to stand on.

Matt, Don't give up! Did your pre-op consults and test results support the fact that you do have co-morbidities? If you need more convincing evidence, you may have to have some further testing. Did Dr. Barba's office give you any advice on how to proceed? The answer to your question about whether the insurance company should know what they're talking about--Yes, they should, but no, they don't. I worked for a major insurance company (as a paralegal) and they often gave me the wrong information when I called customer service about my medical insurance. The customer service people have superficial training and if the question doesn't fit the answer they have been told to give, then they are at a loss. Get your evidence together, ask to speak to supervisors, ask for them to put their reasons for denial in writing for you, appeal, fight. Good luck!!

My pulminologist and sleep study reports sleep apnea .......they put me on a CPAP.  Every Doctor including the PCP and Cardiologist wrote that they recommend the surgery. I am 5ft 11 and 472lbs so my BMI is way up there. I am going to try and speak to a supervisor at Aetna. My surgeon's office just said sorry and wished me luck.

I'm sorry you're having to go through this at such a late time in the process....If my surgeon's office said, "good luck" and failed to help me get approval, I'd change surgeons SO fast it wouldn't be noticable as an eye blink!    Dr Aranow is appealing (once again) to the CT state legislature about this entire insurance company/bariatric surgery coverage mess.  He's asking for pre and post ops to come to his meeting about it and possibly go with him to the legislative sessions and appeal to our state reps to make them pass a law that ALL insurance companies HAVE to cover bariatric surgery. You should go to his meeting.  Fight for this cause...maybe you can switch to him as a surgeon or someone else that fights with the insurance companies on your behalf, while you're fighting on your end. Could it be that your insurance policy changed for 2008?  I know that my BCBS had some minor changes in it from 07 to 08.  YOu have to be a bee in their bonnets at all times. Like someone else wrote, call, ask immediately for their supervisor, then ask for that person's supervisor. These ins companies are just getting ridiculous whie they're making money hand over fist from us little guys. FIGHT< FIGHT< FIGHT.....Don't give up on this....you need this, just from your BMI alone... Keep us posted paula

Here is Aetna's policy on WLS:  http://www.aetna.com/cpb/medical/data/100_199/0157.html 

Ummm HELLO... do they not realize that you can die from sleep apnia and asthma? I know for a fact that Aetna will cover it but it depends on if your company has the rider. Good luck in fighting it esp since they told you it was covered.

Matt,     Keep fighting man! I myself will be paying out of pocket for my surgery. Unfortunately, My company does not carry the rider required to cover WLS. It was dropped in 2006. When I found that out, I went into another spiral of emotion and overeating. ( DONT YOU GO AND DO THAT!)  I tried again to do it naturally and failed again. I got to a point late last summer where I realized I had to either take action or die. I have resolved that no insurance company will dictate how my health is treated. I refuse to let some corporate stooges who have no interest in my well-being decide my future. I am days away from receiving a surgery date and to be honest I still don't know for sure how I am going to finance this. Thankfully and ironically, the insurance company has been paying for most of my pre-op testing. If I can't take a loan out myself, I plan to lean on my family for help. Or, beg, steal, and borrow to get it done. NOTHING IS GOING TO STOP ME!!! Don't give up Matt! Do whatever it takes to get this done and get your health back! I'll be thinking and praying for you. God Bless, Jim