DENIED

Hello everyone, I found out today that I was denied for GB surgery because I have not been Morbidly Obesed for atleast 5 years and Aetna is the Insurance Co. but they do not have this in their clinical policy which states everything that one needs to know in order to get this surgery approved. I had over 100 pages of medical info that was faxed and I did everything that they ask for and still DENIED!!! Has anyone else been denied for  this reason? If  so what did you do? Thanks for any info that you can give me. I do know that I am not giving up!                                                                                       Katina Rye

ok... let's say (just to have a number) that you became MO 3 years ago.... did something happen around that time that caused you to gain the weight?  like a leg or back injury?  some sort of illness? anything that may be "blamed" on your RECENT weight gain?  or has your weight gain been a life-long slow and steady progress and just recently you went over "the line" of being MO? that may be your only save, is if there is/was an issue (injury or illness) to "blame" the weight gain on... if you injured your back and suddenly became less active, the inactivity obviously was the cause.  and because of being heavy with a bad back, you can't exercise the way you should to lose (or even maintain) weight.  THAT scenario, I would think, would be a reasonable grounds for appeal. if you just gradually crept up to becoming MO, then their stance is that you gained slowly, you can probably lose on your own if you just try.... and if you can't, then by the time you're done trying, then you'll probably have been MO long enough to THEN have the WLS. best of luck.

Hello, Yes I have denied 3 times & they keep coming back with my BMI hasnt been over 40 for the past 5 years (it dropped to 37 Three years ago) I delveoped heel spurs & havent been able to be active for the past 2 years, so the weight crept up to my highest BMI of 44 right now. You can have a BMI of 35 or more & still get Aetna to approve you IF you have high blood pressure,diabeties or sleep apena. It has to be one of these listed co morbs. I have GERD, arthritus, depression, swelling of the legs, back & joint pain & i get boils where my thighs rub together. & that wasnt enough for them. My surgeon is going to do a peer to peer & right now that is my only hope  I have Aetna POS & have been on this WLS journey for a year now & AETNA has been a nightmare. I also had over 100 pages faxed to Aetna & my surgeon's staff laughed & said wow, they cant deny you with all this, she was shocked when they did. Everyone always says Keep fighting, dont give up, so I will keep on fighting, as you should also. p.s.  I wouldn't mind even paying for  the legal help, IF I thought they could win this for me, but scared to loose the $$ if they can't. AETNA STINKS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Getting legal help was the best and the simplest part of the process for me. I only wish I hadn't weighed the pros and cons for so long... I was denied for lap-band surgery by Empire Blue in Feb 2006. I finally decided to hire a lawyer in May. My policy only had one level of appeal so I just felt like I couldn't risk losing that one. What's really nice is, once you hire a lawyer you don't have to fight anymore, the lawyer does that for you. I think of all the other things I have spent money on in my adult life; what could be more worth it than investing in your health and potentially saving your life? I had my surgery on July 14 and I am happy to say I have lost 35 lbs so far and I am feeling so much better!! Good luck!

Thanks for posting your messages but you all don't completely understand. I have several co-morbs; 1) Obstructive Sleep Apnea so bad to where I lose my breath 10-12 times per hour, so ofcoarse I have to sleep with  a C-PAP machine. I have high blood pressure so bad to where I have to take meds everyday for it but still have a terrible headache everyday! Acid Reflux, on Nexium for that. Lower -back pain, as well as hip and knee joint pain in which I have gone through physical therapy and they have paid for it! I could go on and on but that is just to give you an idea and ALL of this is documented through Doctor after Doctor and they are still denying me! I also am waiting for my Surgeon to do a Peer to Peer Review to see if that too will be denied! I will just keep praying and would deeply appreciate your as well!!                                                                  God Bless You All,                                                                      Katina Rye

Hello, How low has your BMI gotten too in the past 5 years?  Per Aetna's policy you can have a BMI of 35 or more in the past 5 years IF you have 1. Coronary Heart Disease 2. Type 2 Diabeties or mellitus  3. Clinically Significiant obstructive Sleep Apena 4. Medical refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90mmHg diastolic. So right there you have 2 of them.  I dont know how many times you were denied, but you have good reason to FIGHT.  Was the reason there denying you because your BMI maybe was lower than 35 in the past 5 years??.. Still reguardless Keep fighting, if you have the $$ look into getting the legal help.

I am confused by this situation.  Aetna's clinical policy (which btw was revised on Sept 8) states 5 years of severe obesity.  What is BMI for severe obesity?  I didn't realize you are required to have BMI of 35 for five years with co-morbidities. This forum is really informative.

I think  "Severe Obesity" is a BMI of 40 or greater. I have heard alot of people get approved even if they havent been severe or morbidly obease for 5 years..so I think it has alot to do with whatever mood the person is in when they get your file.

Hi I have been denied by my insurance company I did one appeal on my own and was still denied due to my BMI being under 40 but I had the comorbilities to have it approved they were a real pain in the a%^!!! I hired a lawyer Gary and he got it overturned I paid for the fast process witch only took a month for the state to overturn and allow me to have surgery. It was well worth the money to me you can ask Gary he will tell you if you have a case or not he is extremly helpful. I don't know about how long out of state works but he does do out of state I happen to live in the same state as him. Paying for a lawyer is better then self paying for surgery!!!! I just had my surgery three weeks ago and doing well I was banded.