Please read and give me advice!

Hello all. I began this jounrney to my weight loss surgery in March of 2010. I visited Dr. Custer in Ohio and he felt I would be a good canidate for the Lap band. I have aetna insurance with Buckeye as a secondary. (I just got Buckeye within the last month). So, with aetna you can do the 12 week nutritional class or the 6 month with your pcp. I did the 12 week class at the barix clinic and also met with my pcp once every 3 months. My pcp was very supportive-filled out in detail what I did during those 3 months on my file. There was other ciriteria to meet of course and I did.

I am 31 years old and weigh 285. Been dealing with obesity for my whole life. The lady that I am working with from Dr. Custers office thru all this said I did everything 110% correct. My file was submitted to aetna on June 22nd 2010. July 3rd I got word that it was denied and would go to appeal. I was told that the medical reviewer denies 9 out of 10 cases that get to his desk..so it went to appeals which means that in July it went to my employer which is the East OHio Conference. I wrote a letter to go with my file at that time telling more about myself and all the options i have did before to try and lose weight....a 2 page letter that I wanted to go with my file so that I wasnt' just a number. Well, I head back from the lady at Dr. Custers office yesterday morning and she said it was denied again. She feels that the East Ohio Conference are just siding with Aetna becasue they don't know how/or what to do to handle this. I got on the phone after that call and called and spoke to the lady at the East Ohio Conference that handled my file and asked her for more info. What she told me is that she feels I should try optifast again....she feels that there are other ways I can lose weight..she feels that I should do another  month diet...I got all these answers from her and it was like her opinion!! She kept referring to an insurance program that the east Ohio Conference used to have that was more strict on guidlines for weight loss surgery..I feel like I have hit a very hard wall.

I KNOW I have met all the crriteria to get the weight loss surgery. I did everything 110%. If I appeal this again..it will just go back to the East Ohio Conference. And I was told within time the 12 week nutritional class does expire. So I will have all that plus more dr. offices out of pocket to meet my deductable yet again.

What do I do? I feel sick at the thought that this means I am back to the drawing board.

Any advice out there? I need it terribly.

Thank you,
Angie

 
Have you looked at your policy regarding WLS with your own eyes?  Have you personally read the requirements?  If so, please post the requirements and let's go through them.  If not, get a copy and post them.

If you met all the criteria and they still deny you then you go to the state ins commission.  

But post it here first and let us go through each item so you have all your ducks in a row,

BTW, you would not be a good candidate for banding.  It's not a good surgery type for anyone let alone someone that has more than 75# to lose.  It's not designed to be forever, maybe 10 years but usually 5.  Ins co's are switching to a 'one surgery in a lifetime' policy.  Think long and hard about this. 

If you want restriction only a sleeve is far more effective and tons safer long term.

Here are the guidlines that I got off their webiste. I followed these rules 100% along with my PCP. I just feel like I am stuck-but I know I did everything I could. I don't want to settle with another denial based on what someone "thinks" I should do. Frustrating. I feel like I will give up if I settle with it.

*********************************************
Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic sleeve gastrectomy, open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met.

Selection criteria:

1. Must meet either 1 (adults) or 2 (adolescents):

   1. For adults age 18 years or older, presence of severe obesity that has persisted for at least the last 2 years (24 months), defined as any of the following: 

      1. Body mass index (BMI) (see appendix) exceeding 40; or

      2. BMI greater than 35 in conjunction with any of the following severe co-morbidities:

         1. Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in CPB 004 - Obstructive Sleep Apnea in Adults); or
         2. Coronary heart disease; or
         3. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management); or

         4. Type 2 diabetes mellitus

   2. For adolescents who have completed bone growth (generally age 13 in girls and age 15 in boys), presence of obesity with severe comorbidities:

      1. BMI exceeding 40 with one or more of the following serious comorbidities:

         1. Clinically significant obstructive sleep apnea; or
         2. Type 2 diabetes mellitus; or

         3. Pseudotumor comorbidities.

      2. BMI exceeding 50 with one or more of the following less serious comorbidities:

         1. Medically refractory hypertension; or
         2. Hypertension; or
         3. Dyslipidemias; or
         4. Nonalcoholic steatohepatitis; or
         5. Venous stasis disease; or
         6. Significant impairment in activities of daily living; or
         7. Intertriginous soft-tissue infections; or
         8. Stress urinary incontinence; or
         9. Gastroesophageal reflux disease; or
         10. Weight-related arthropathies that impair physical activity; or

         11. Obesity-related psychosocial distress.

2. Member has attempted weight loss in the past without successful long-term weight reduction; and

3. Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary surgical preparatory regimen):

   1. Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record at each visit. This physician-supervised nutrition and exercise program must meet all of the following criteria:

      1. Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records; and
      2. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote); and
      3. Nutrition and exercise program(s) must be for a cumulative total of 6 months (180 days) or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least three consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.)

      or

   2. Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multidisciplinary surgical preparatory regimen of at least three months (90 days) duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions:

      1. Behavior modification program supervised by qualified professional; and
      2. Consultation with a dietician or nutritionist; and
      3. Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen at each visit. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.); and
      4. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
      5. Program must have a substantial face-to-face component (must not be entirely delivered remotely); and
      6. Reduced-calorie diet program supervised by dietician or nutritionist.

   and

4. For members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, pre-operative psychological clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and postoperative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.

 
I don't see anything in there that permits her to do this.  I'm assuming your company is self funded?  This is usually how they behave.

I would try a peer to peer review, if that is denied then an external medical review such as your state insurance commission.  During the peer to peer the doc may opt to explain that you have met all requirements as outlined by the policy.

She can't do this, she sounds like one of those WLS bigots.

After my first denial (the lady at the surgeons office said that the medical reviewer practically denies everyone) my PCP and that reviewer did a peer to peer and he requested my entire file-18 pages of info. Still denied it which was why it went back to East Ohio Conference. I don't know if they are self funded..but when I spoke with the lady at EOC she told me that she felt I should try optifast again...or a supervised hospital program...it just felt like it was her "opinion".

So, how would I request another peer to peer? Have my PCP contact the lady I spoke to at the East Ohio Conference?

I greatly appreciate your help.

And advice! I feel alone doing this!

Angie

 
Do you have any appeals left?

Exhaust your appeals explaining that you have met every single insurance requirement and if they deny you then get a 3rd party person in there.   State insurance, etc.

You can also opt to hire Walter... i forget his last name but I can get it for you.  It will probably happen sooner with him, but cheaper with the state ins.

When does your fiscal year end?  Could they be putting you off because benefits will change and perhaps WLS won't be covered?

Thank you so much for your input. My insurance is Jan-Dec. I started this in March thinking that I would have all year to get the band..and my fills. And now this. My deductable is close to being met of course. How would I find out how many appeals I get..and if I appeal again I know it goes back to the East Ohio Conference. The thought of talking to the lady from EOC again makes my stomach feel sick. BUT I know I have did everything 110%....

Bottom line here, if you have met each and every requirement they cannot legally deny you surgery. Sooooo, this is where you find your inner ***** and go for it. Fight for your surgery, fight for your life. If you want my phone number I'll PM it to you and I will do anything I can for you.

Fight the *******s.

Angie,

I have Aetna insurance and also did the 3 month Multidisciplinary program.  My daughter also has had surgery and so has a friend of mine, all of us having Aetna insurance.  I'm sure you have looked at their clinical bulletin 0157 for the 'requirements' .  If you meet those requirements, there should be no reason why you can not appeal and get this overturned.

In your denial letter, what is the reason they are giving you for denial?  I was denied, my daughter was denied, and my friend was denied.  I put together appeals on all three of them and eventually all three of us were approved. 

Basically what it comes down to is they hgave requirements, and if you meet them, you will get approved.  If you are denied, think of it as a bump in the road but don't give up!!

I will be glad to share the letters I wrote in our appeals.  PM me if you'd like.  

Again, read the denial letter and find out the reason they are denying.  Then, provide that information to them so the decision can be overturned.  

Nan 

I appreciate everyone's input.

I have found myself wondering why I have been denied 2 times. When I was denied by Aetna the first time, the lady that I have been working with at the surgeons office told me that the medical reviewer from Aetna that denied my case denies practically everyone. As soon as they seen which reviewer I had they knew it wasn't good news. Well, with how this plan is set up-once it goes to Appeal- it goes back to the Employer-which was East Ohio Conference.

Once the surgeons office called me this week and said that it was denied again, I called there. Spoke with the lady who had my file. She was half rude and I could tell she didn't have a clue what the requirements were herself. Here is a what her letter that I got yesterday said.

Dear Mrs. Garrabrant.

This letter is in response to your appeal dated August 4, 2010. regarding the denial by Aetna for a laparoscopic gastric banding procedure. At this time, we must concur with Aetna's determination.

Angela, I'm not certain if you are aware of anothe rweight loss provision under the Conference Health Benefit Plan that may be helpful for you at this time. For more info, please call. xxx-xxx-xxxx.

Sincerely...
xxxxxxxxxxxx


That was all I got. No reason why. Even when I called her she told me that she felt that I should do another 6 month diet-or wait until March so I can begin again. She told me to try Optifast again. I asked her if she recieved a letter I had mailed to the office-kind of my story..etc. So that I wouldn't just be a number. She did get that letter and told me she has 2 daughters herself and she couldnt' approve something that could threaten my life (surgery for weight loss)..CAN SHE/THEY do this????????

My first denial with the medical reviewer from Aetna didnt' even give a reason-and he did a peer to peer with my PCP who supports me and this surgery 110%.

I don't want to settle with this. I feel I have been treated wrongly. I am going to call the surgeons office on Monday and see what I can do next..I don't even know how many appeals I have left but I know that if I appeal again it will go right to the East Ohio Conference.

Who else can I get involved? I feel as if I am in sinking sand!!

Angie