HELP -Please! - I worked hard - scheduled - denied -AETNA

I told myself not to get excited about this until it was over and now I am devastated......I am schedule for my RNY in 10 days and I got the call today that my insurance does not cover any WLS. I called Aetna almost a year ago and asked over and over to make sure I was covered. I gave them the medical codes and everything and they told me yes and gave me the criteria for the surgery. I have spent the last 9 months getting all of the consults and tests and NOW that it is less than two weeks from surgery my Dr's office called and said that Aetna said it is not part of my policy. Actually first they told them no and then they called a different dept at Aetna and they said yes it was covered and told them to fax everything over and them another higher up told them that the other people were wrong and that it is a common mistake by customer service people. Shouldn't they know what they are talking about when you give them your policy number and group info........WHAT CAN I DO NOW? DO I HAVE ANY OPTIONS WITH FIGHTING THIS?

What Aetna do you have?  I have Aetna PPO OpenChoice and I was approved on the 24th on the first time.  Aetna Most definitely covers it. 

Same - in fact the only exclusion note I could find in my employer's handbook was this.....

Treatment of weight loss when another underlying severe medical condition is not present; outpatient prescriptions are NOT covered even when there is an underlying medical condition.  I have sleep apnea and asthma ....both because of weight.....on a CPAP machine also have heart disease in my family history with both my mother and father.Do you think I could fight this?

I definitely do not know enough about any of this to give an opinion on whether you can "win" this.  I definitely know you can "fight" this.  I have read on here that there are some employers that choose to not buy the bariatric portion of insurance policies.  I do not know if your company has done this.   You do have to have a co-morbidity IF you have a BM of 35 - 39.  At a BMI of 40 you don't have to have a co-morbidity.  Sleep apnea is a co-morbidity so you do have other severe medical conditions.  I would definitely call Aetna and ask again.   Then I would call your human resource department and find out if they have added that exclusion.   I will definitely keep you in my prayers. 

We went through the same thing with them-- after 7 months of diet and jumping through hoops we were denied because of an employer's exclusion----one that we asked about early on and were told didn't exist. Good luck to you!

Ok, from a billing point of view I must ask .. was a PA # not obtained from your surgeon weeks, if not months, prior to a surgery date?

I don't know what that is .....but I was shocked that they gave me a date and then all this happened days before

"Prior Authorization" ... are you keeping good records / notes of all your calls? To include names, dept.'s, extension #'s.

So far there is some hope........we wont know for sure until Monday. I called Aetna and spoke to them again and then I spoke to a healthcare advocate at Aetna for Lowe's (my employer). She at first said no the do not cover it, but then looked and saw that YES they do. She then called someone at Aetna and her manager and they too said that it was covered. We were all on a conference call and they said to send in my appeal, but I questioned that since that can take 180 days it says. Then the healthcare advocate got a little testy with the service rep since it was their mistake. She got back on the phone and said that the only reason they denied it was because it was at a non-network hospital. OMG another excuse! They have had many different replies on this but the denial just said it was not covered. We then checked the hospital and it WAS in the network! The surgeon's office wrote "New Britain Hospital" and it is actually called "Center of CT Hospital at New Britain" So now Aetna and the Dr's office are suppose to talk on Monday and reschedule me if it all checks out. I'LL BELIEVE IT WHEN I SEE IT. I refuse to get excited until the IV is in my arm and he is about to cut.

I'm keeping you in my prayers. I hope it all works out and that your date is made on Monday for you!  Shelly