Hoping to become a DS-er. Denied by Aetna

Hi All - It's been a while since I've been on OH.  I had RNY 11 years ago.  While I was a "remedial loser" from day 1, I did manage to get down to around 195.  Over the last 2 years, I've been steadily gaining even though I've upped exercise with a personal trainer and have watched my diet.  I saw my surgeon and he found (through an endoscopy) that my pouch is just fine but my stoma is large (he may have said "huge").  We discussed options and he is suggesting a revision to DS.  After tons of reading here, I agree.  

Aetna has denied me.  My insurance policy has no mention of WLS or even the term "bariatric" but Aetna insists my company has it listed as an exclusion.  This is the terminology in my policy under Exclusions:

24. Obesity – Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a part of the treatment plan for another Sickness. Medically Necessary charges for Morbid Obesity will be covered.        

It seems like that last part implies that surgery should be covered.  I'm bummed because I could have taken my husband's insurance (BCBS IL PPO) but chose mine thinking it was better (and reading it to make sure there was no bariatric exclusion).  I contacted a health advocate and while she agrees it doesn't make sense, she got the same answers.  I'll have to wait until January to switch to my husband's policy and even then won't find out for sure if they cover it after I'm a policy holder.  I'm curious if anyone else has encountered this?

Thanks in advance.  I hope to join you all on the DS side some day.

Jeannie

I was excluded an my insurance but I never looked up the exact wording.

I think what that means they will cover any illness caused by morbid obesity (diabetes, sleep apnea, etc etc)
but they won't cover the operation to fix the underlying problem.

STUPID< STUPID< STUPID insurance companies.

I hope this all works out for you.  I had BCBS of IL PPO back when I had my DS in 2003.  I had no problem getting approval.  At the time my company had a self insured plan though.  So that may have made a difference.

Jeannie, I am sending you a pm. Be on the lookout for it.

Larra

Hi,

I may be totally off track here but I thought as far as your insurance covering WLS or not was to do with your employer not so much your insurance? I had Aetna and had no issues getting them to cover my DS and I even went out of state for it. I know I have seen on some BCBS policies that they will not cover your DS unless your BMI is 50 or over. I am actually on that policy now. Insurances who can understand them! Good luck with this Jeannie

Trish

I do not know all the information on how to go about doing it, but I believe you should be able to make an appeal with your current health insurance to cover the surgery. Both based on how they worded it in the plan info and being that it is medically necessary. Hopefully someone else pipes in about that since I have not been through the process myself. Good luck!

First off - THANKS TO EACH OF YOU *****PLIED TO MY POST!  I'm just remembering the amazing support and information that OH members give each other.  I am truly grateful.

I met with my the HR person at my HEALTH CARE company that manages our benefits today. Indeed, we are self-insured and our plan is sponsored by AETNA.  I told her my issue and pointed out where it says "Medically Necessary charges for Morbid Obesity will be covered" in the Summary Plan Description (printed out all 105 pages of it - trees forgive me) which is posted on our company intranet. She just kept saying "bariatric surgery is not covered", over and over. She seem just a smidgen annoyed with me.  :)

I also told her that if bariatric surgery is not covered, the language in the document is misleading.  "Bariatric surgery" is never mentioned in the document but many other specific exclusions are (cosmetic surgery, vitamins, etc.).  My surgeon's office does not accept self-payment for this procedure, so I have no options.  I asked her if the company could terminate my policy so I can buy insurance thru the IL health exchanges and she said no.  I feel like they've tied my hands.  

She also kept saying that the coverage choices is based on benchmarks and medical direction from experts.  She seemed surprised when I told her that even the health exchanges (in IL) cover bariatric surgery.  She seemed annoyed that I told her that the AETNA rep told the patient advocate that my company chooses not to cover bariatric surgery.

So, as it stands, my HR person is reaching out to AETNA for more information.  She asked me to supply the "CPT codes" from my surgeon.  I have a call in to his office.  I'm hoping because of the "RNY failure" (enlarged stoma issue), and because it's something has to be corrected, something may happen with AETNA.  I'm afraid they'll come back with the decision that they'll cover the charges for the stoma to be fixed but they won't cover the revision to a DS.  She told me they don't "override the policy" for individual cases.

Thanks for listening/reading.  I welcome any other thoughts or ideas on this.  Thank you again!

Jeannie

Can I ask you what surgeon you have chosen for your DS...I also would like to have a revision, but can't seem to find a surgeon....and can I ask who your dr is that recommended the revision...thanks

Hi Andie - I sent you a PM.  The surgeon I'm working with is Dr. Guske.  Would love to hear from anyone who had an RNY to DS (or just a DS) surgery with him.  Good luck to you!  

Jeannie

Does Dr Guske even do the DS, let alone take down the RNY then revise with a full DS?  There are only a handful of DS surgeons that will do that.  Are you sure you won't end up with ERNY like Vitalady?