Illinois law and Weight Loss Surgery

Hi all-

I am an Illinois resident, employed full time in Illinois, by a company based out of NY.  I have been denied 2ce by Aetna, and denied once on appeal, by a plan that clearly allows for WLS.

I have a BMI of 62, have 8 yrs of medically documented weight history, have sleep apnea, high cholesterol, lower extremity edema and PCOS.   I have 2 separate 6 month medically supervised weight loss programs in the last 2 years (one in 09 and one in 10).  I have a psych study, and recommendation from an LCSW I see regularly.  I am attending a program at a Baratric Center of Excellence, in an accredited hospital.

So, I am obviously frustrated and have to plan my next steps...

Any thoughts?

Thanks for reading!

Maria

WOW!  What is their basis for denial?  If the plan allows, I am guessing they are picking some tiny detail.  Find out what it is and attack that particular detail.  Sometimes they pick on the documentation----"it is not in the form they want".  I had trouble until I found exactly what the issue was and then fixed that issue to their satisfaction.

There is also an Insurance Forum here on OH where a lawyer (used to) visit regularly.  I would ask there to see what others might say.

Welcome to the Illinois board. You will find that we are very helpful with ideas and support.
Just a dumb question, but is your doctor on your insurance plan (Gastric Surgeon)? I would also be doing what Dawn suggested, call the gastric department of your insurance and see what one thing is keeping you from getting approval.

Good Luck,
LISA

I am waiting on the letter from Aetna to tell me exactly what I was denied for...   mY surgeon and the internist I went to for medically supervised weight loss are both on my plan... I am trying to discuss on the insurance forum as well...  lots of folks with Aetna there, I was just curious because I know Illinois has laws about obesity- but I am not overly familiar with them...

thanks for all the advice/support, I realy appreciate it!  : )  I will keep you all posted!

Maria

You asked for thoughts, so here are my quick ones:

You'd have to hear their particular reason for the denial. It sounds like you have done everything right. Just wait and see.

They could have denied you if you asked for a "VGB" because it is not done much anymore because of complications and failure rate. Or did you mean the "VSG?" They could have denied that because some plans do not recognize it as a viable, long-term WLS, particularly for people with a high BMI like yours.

If you have not considered it yet, perhaps you would consider getting the duodenal switch. It has the best long-term weight loss results and resolution of comorbidities such as diabetes. Here's a site that might be helpful: www.dsfacts.com. After I get my protein and vites in daily, I eat what I want, including desserts. It's awesome!

If Aetna denies you, some companies like Starbucks will hire you on for part-time and cover your WLS, even the DS. I almost went that way. You have to work a certain number of hours and then you qualify.

I had Aetna and they said "the DS? Of course, my lady, here you are!" Seriously, it was disappointingly easy for me to get the DS through our Aetna plan. After doing research on WLS for over two years I wanted a battle. I wanted to whip out all of the studies I knew by heart. And got...a life-saving surgery easily instead. Oh, well. All's well that ends well!

I wish you luck.

Best of luck to you,

Nicolle