first post...hurdle in Aetna approval...many tears...FRUSTRATED! (long)

I found out today that I was denied for the Lap-Band by Aetna.  I am devastated as I worked my butt off to meet all the requirement criteria.  As a control freak, I am starting to fear my surgeon did not submit everything properly...I mean, I had it ALL...so how could I be denied? 

I have been compiling requirements since last summer and was insured by Cigna.  My employer switched to Aetna for 2011.  This surgeon also separated from his partner and went into practice alone, having to get re-certified with insurance companies.  I was ready in January, but they were not yet confirmed with Aetna.  I have been waiting on them these few months to file.  Do either of these factors have anything to do my denial?  I don't know. 

The contact at the surgeons offices says I was denied for "too low of a BMI for the last 2 yrs".  2 YEARS??? None of the requirements state that, I thought.  I came home and read I needed to have "presence of severe obesity that has persisted for at least the last 2 years"...so I was proven wrong...sorta.  While I do have a "low" (not low enough for ME though) BMI by some standards, I do still have a history of "BMI greater than 35 with a co-morbity"...that being years of hypertension that I am medicated for.  I was also recently diagnosed with PCOS.  My BMI averages 37 over the last 5 years, which I provided to the surgeon.  I did all the necessary doctor managed weight loss for 6 month, psych clearance, nut, battery of cardiac testing due to my hypertension, great Dr. recommendation letters...yada yada yada...I've jumped through every hoop necessary. 

I was a bit disappointed by the "sorry, you were denied"..."see ya, bye" feeling I received from the surgeon I picked (on great recommendations).  In talking to them today it seems they feel an appeal is not even an option.  I asked if the doc would fight with Aetna for me...she said he already had a peer to peer review.  I do not take no for an answer so I call Aetna.  They list off a battery of reasons I was denied, mainly "insufficient information".  I.E. no documentation of morbid obesity of BMI 40 or 35 with co-morb (not true), no docs of supervised weight loss (I submitted 16 pages worth) etc etc.  EVERYTHING they sited, I have provided to my surgeon.  I asked the process to appeal...the agent recommended a peer to peer session, for possible reversal of the decision, with the surgeon and confirmed for me that one had not yet been had (remember, the surgeon rep said the doc had the peer to peer already).

I called the surgeons office back asking if we could discuss it more and they said they'd call me back in 30 minutes...I received no call.
 
I am so frustrated.  I do not feel I can fight the decision to deny me without the Dr. backing me...I mean they are the experts, right?  I know decisions have been overturned.  You guys know the efforts that go into making this happen...Was this all for not?  I am having this surgery...I want to change my life!  I have been on obesity scales in my medical records all of my life and I want OFF.  Do I have to get the diabetes my doctors fear for me before I will be taken seriously?  Do they not see I want to use this tool as my opportunity to turn this life around?  In the long run the insurance companies costs will be lower as I will be a lower risk to them. 

I am baffled.  Anyone have a similar story?  Anyone successfully appeal an Aetna decision? 
Thanks in advance!

I'm so sorry to hear that you were denied. I have Aetna but also had a BMI of 48, so that's the main difference I guess.

You definately should appeal and yes, the surgeon should help you. You can also employ your PCP doctor and have him/her write a letter. Does your surgeon employ an insurance specialist. My surgeon actually has a former insurance coder working for him to help navigate the red tape with insurance companies.

Were you tested for Sleep Apnea? It's very common in obese patients and counts as a co-morbidity.

There are others here that know more about the insurance thing than I do so I'm sure you'll get plenty of good advice.

Hang in there and don't give up!

Lisa O.

Thank you Lisa!  What great success you have had, congrats!  I truly believed I was a slam dunk and expected the approval and even had my sights set on a surgery date. 

I have never been tested for Sleep Apnea, no.  I hate to hope for a co-morbidity but considered looking into it today...I really dont think I have it though...who knows. 

I am sorry you have had to go through this.

Generally, they want to see BMI between 35 - 39 and 2 co-morbidities -- PCOS is not a co-morbidity (as devastating as it is to you and your life).

If hypertension is your only documented co-morbidity, you may not qualify based on BMI.

Take the weekend to take some deep breaths and formulate a calm, but persistent demeanor.
I would contact the surgeon's office, and speak with the insurance co-ordinator -- ask what they think your best 'plan of attack' is -- ask if it will helo to come in and sit with her to draft additional documentation.

To her, hopefully, you are a real patient ---- to the insurance company you are a voice on a phone and a file number.  Stay pleasant and try your best to 'enlist her support and help'.

If all else fails, it might be possible for you to self-pay or go out of area for Band or VSG ----

Can you gather up all your records and take them to a new doc to appeal?  I know of course that all payers have different rules but I qualified at 35.9 with "only" hypertension as a comorbidity?  Granted, I'm on 3 meds for the hbp and it's still not very well controlled.

 I have Aetna also.  When I was researching wls I went on Aetna's website.  They have the complete criterea for wls.  You have to have a BMI of 40 or 35 with comorbidity.  Why not go to their site and take a look.  That way you're armed with all the info.  Good luck!

I also have Aetna.  My PCP submitted a letter along with documentation of all the weight loss attempts I've made: Weigh****chers, Adipex, etc.  I also have chronic back pain, arthritis in my back, and tore my Achilles Tendon in August.  Throw in high cholesterol and high blood pressure. And my BMI was 48.  My PCP still wasn't sure if all that would be enough. 

Have the Sleep Apnea checked out.  I didn't think I had it either (my husband has a severe case so I know what it is), but the test results came back that I did have it.  Not bad, but I still required the CPAP machine.  I'm pretty sure that the Sleep Apnea diagnosis was what got me approved. 

It's worth a shot!  Good Luck!

Don't give up, go ahead and appeal. I was denied 3 times for insufficient info but finally got it all to the ins. co and got approved. Just be persistent!

I have Aetna also and had no issues getting approved but my BMI was over 40 . I would ask for copies of all your records and then call the ins. co.  and go over everything and see what you need and then honestly I would look into another surgeon. Your low BMI is probably what got you denied and you are probably gonna have to jump thru a few more hoops to get approved .  It could be that they did not submit everything or it could be the ins is going to require more than they submitted based on the fact your BMI is low. I would definitely appeal and see how it goes. But I would get a copy of your file and KNOW what is in there and what the ins is looking for.  Good luck !!!! :)

Thank you all, for your replies.  I used to come to the boards for ammunition and pre surgery knowledge and now the boards just make me cry because of all the success stories.  I want to be a success story!!!! 

I went away for Spring Break...had a great time away from reality...now it's time to do this!  I have an appointment with the surgeon tomorrow, as we are nearing our last days to be able to qualify for a peer-to-peer review to turn this around.  If we cannot get this over turned in a PtoP review, I have to go full appeal.  My goal is to review my file and appeal to, even him, to fight with me on this.  

I'm frustrated because Aetna's qualifications pretty much say hyptertension isnt even enough anymore if it's controlled...they want you to be full on heart disease! 

I am doing this to AVOID heart disease, which will be coming.  To AVOID diabetes...which is coming. etc etc....I know ya'll already know all this...just need to vent.  ;-)

Wish me luck!  While I am not a frequent poster, I am very grateful for these boards...and I THANK YOU!
Carrie