Newto the board/Aetna insurance issue/self pay?

Hello All! I have been a lurker for the past few months. You all have helped me keep my spirits up during this 6 month supervised diet (aka - waste-of-time.) However, I do admit to a bit of jealous as each of you got dates and made it to "the other side". I finished that earlier this month and insurance was promptly denied. They need 5 years of medical history - and per their info you have to have been MO for at least 5 years - which was defined as BMI>40 or BMI>35 + comorbidities. I have plenty to show that I was >35 for the past 7 years (and am >40 now) but sleep apena was not diagnosed until last December. They've sent the appeal in to prove the >35 but I'm afraid the undiagnosed sleep apnea is going to kill it. Has anyone else had a similar issue w/ Aetna? Any hope? Plan B is to self pay. Any one have any feedback on negotiations w/ hospital/surgeons for self pay after insurance denial? At this point I'm so far into this journey, I think it needs to happen one way or another but obviously would still like to do it as economically as possible. Thanks! Lynn

Don't give up. Unicare did the same to me and my husband but we kept appealing. We both were approved after the second appeal. Some insurances just won't make it easy. Show them what they want, send in any and all info from whatever doctors you have seen in the past five years. Good luck! Stacy

appeal appeal appeal,,, gather pictures from the past 7 years letter from your pcp, any doctor you seen that weighed you and or said you need to lose weight. write a letter yourself telling them why you NEED this surgery,, vicki

I agree with Vicki. I created a photogrpahic journal of weight(put a bunch of pictures on about 4 pages so it is easy to print and mail or fax) starting at age 7 so they could see me slowly get bigger and bigger and bigger....(I think you get my point...) This shows that you have been obese for a period of time and it gives you a face to the insurance company and not just a pre auth number. write a personal letter why you think you shoud have and all the things that have led you to this decision tell the m how much research you have put into it and that you know the benefits and the risks of this surgery but it is in your belief that htis is the best option for you. Don't go the slef pay route until you have appealed because sometimes insurance uses appeals to weed out the people who aren't really serious about hte surgery and give up after the first try. stay focused. if you self pay you also don't get to take advantage of the Provider writeoffs that the insurance companies get and will be paying a lot more for your surgery.

Lynn, Talk with your pcp because sleep apnea is not the only comorbidity out there! Hey everyone...help me out here, k? These are the ones I can think of off the top of my head: sleep apnea PCOS Irregular periods Difficulty concieving joint pain, back pain gall bladder asthma due to weight diabetes Insulin resistance high: Cholesterol, triglycerides, blood pressure I read recently that migraines is more common with obese people...although I don't know if that is typically accepted as a comorbidity. Before paying out of pocket, I would DEFINATELY appeal at least a few times! Good luck!!!! Sherri

Urinary stress incontinence, I think.

Well Sherri I think u listed all the ones I had except for the stress on my heart and the swollen ankles.

Thanks for the input everyone. I'm plotting strategy for appeal # 2 to be ready. Unfortunately they only consider 4 comorbidities: Diabetes, High Blood Pressure, Cardiac problems & Sleep Apnea. I don't have the other 3.... YET... (that's the whole point of the surgery, eh - - to avoid all that!) :-@ I've pulled their policy bulletin and there are pages and pages of article references that they use as a basis for the various rules. I am researching those sources to see if there's any other wording in those docs that I can use to my advantage. Hopefully I'll find enough where I can argue that if they are saying that the wording THEY picked from the article is a valid justification then if I find something in the same article they'd have a tough time disputing it. I'm going to work on the picture idea too. My weight has actually been an issue for THIRTY-five years - not only 5 - - - and I'm only 40! Do you think a sleep specialist (as in my sleep apnea doc) might be able to (and talked into doing it)make a case that sleep apnea develops over a period of time and perhaps with my readings, it's likely that it's been a long term condition only undiagnosed? I'm struggling with the "evidence" piece. Evidence, evidence, evidence. Sleep apnea is something you specifially have to test for. High Blood pressure - -routine every time you go to doc... easy to find..... diabetes... blood tests are more frequent.... cardiac.... well - my father had undiagnosed heart disease too -- UNTIL HE HAD HIS HEART ATTACK! I feel like I'm going to be penalized because my previous docs didn't recognize the signs and attributed various symptoms to a thyroid condition & asthma. Just because the woman doesn't know she's pregnant doesn't mean she isn't...... I'm not going down without a fight! Thanks for letting me vent!! Lynn

Hi Lynn, I am new to this whole thing. I was told however I needed to get with a support group now because I put it off pre-surgery. The reason was because of my problems over the last five years with AETNA. I was completely expecting to jump through all the hoops and end up, once again, looking at a denial letter. Therefore, I just ignored the whole support group thing. First of all, I know exactly how you feel. The first time through for me was 5 years ago. It sounds like your coverage policy was exactly like mine was then. Our insurance has changed a little and this time it only took a year and a half. The biggest problem was I was sending them everything I thought I needed to only to realize they like it simple. I used to work for AETNA believe it or not, I paid claims. So, I called an old friend who still works there and they basically said don't send more than they can go through with a quick glance. You need to make sure everything they want is there just keep the "package" simple. The last time I submitted I sent only the most recent info. Keep in mind that everything you have already sent is on file already and they can pull it up. As far as co-morbidities; see your doctors and get a simple letter from each. This should include any and all specialists, including your Gynocologist. I don't think the fact that you have not been clinically diagnosed with sleep apnea will kill this. I could not find the time to go to the hospital in the middle of the night and do the tests so mine was just by word of my family phys.. Look for other co-morbidities: PCO, Hyperplasia, Insulin resistance, Hypertension, Hypothyroidism, GERD, Hiatal hernia, Asthma, Diabetes, etc... And the other thing I think helps is your pick for surgeon. I think what made it easier in the end was the fact that I chose a surgeon that was associated with a top ranked program. The Carmel St. Vincent Bariatric center is a whole program and they help you get all your ducks in a row. Everyting you need is on site, from the surgeon to the dieticians and pshyc eval. You even recover in a special "wing" called the Bariatric PCU. The progam isn't perfect but it does make things a lot nicer in the end. I sent three friends to my surgeon of choice and all of them had thier surgery before me. Keep your head up, it can be done. I am proof of that. I had my surgery 3/23/07.

Kim - THANK YOU so much for your response. You've given me a bit more hope. The last packet the surgeon's office sent showed 7 years at >35 Bmi. Not one weight listed in those 7 years puts me under that. I'm going thru Clarian Bariatric and it sounds like a similar set up to St. Vincents - and they are doing all of that for me too. Clarian North has a special bariatric floor for this too. I saw the original letter sent and the listing of comorbidites they put down was extensive. I'm really hoping that the only reason for the denial is that they sent just the documentation from my current doctor which only covers the last 2 years (all I orignally gave them - but I did ask if they needed more..) and once they get the extra pages that cover back to 7 years that it's just check the final box and send the approval. Thanks again. I really hope to get an approval this week......