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I've been working on my prerequisites for my Sleeve for almost a year and have been fighting to get it authorized for the past 3 months. I thought I fulfilled all my requirements but after 2 1/2 weeks of waiting for my insurance company to approve/deny they called me this morning. They cannot approve without medical records from my PCP for a 6 month period showing at least 3 visits with weights where I haven't gained - not even a single pound! But... the 6 month Dr supervised diet period does not count! I don't go to my PCP that often. I try not to. I thought that's what they wanted you to do! I've already submitted records from 2012-2013 like requested. I'm livid and freaking out. I've waited and done everything and if I cannot get this covered in the next few months I will not be able to have it until 2016 due to my work schedule. And, by then I will have to start all my prerequisites over because they will be too old. What now? What can I do?
I'm sick about this. And what makes matters worse is I work for the company my insurance is through! I understand all the ins/outs of insurance better than most!
Thoughts anyone? I'm seriously stuck. :'(
We are excited to announce our OH2015 ObesityHelp Conference speakers for the Saturday Sessions. In addition to a great line up of speakers, this year we have added more fitness activities to the conference schedule.
Make sure to stop by and learn more about both our Friday and Saturday speakers and their sessions. We continue to add more details to the OH2015 agenda, so keep checking!
Join us in Raleigh, NC, October 16th & 17th for two jammed pack days of education, support and celebration! Reserve Your Tickets NOW
HW:330 - GW:150 - MW:118-125
RW:190 - CW:130
Due to technical problems, we will be launching the updates at a later date. The website is temporarily running slow. If you have any questions or need assistance, please let us know.
Thank you for your patience.
Due to technical problems, we will be launching at a later date.ObesityHelp.com is back up but temporarily running slow. Thank you for your patience.
Bear with me because this is somewhat confusing; I'll try to explain it as best I can.
I recently got a BCBS of Oklahoma insurance policy through the ACA exchange website. From what I read through various weight loss forums it seemed like Oklahoma isn't one of the states that has to include bariatric surgery.
Then I started researching more about ACA and bariatric surgery and came across things like this stating oklahoma mandates that it has to be included in all policies on the exchange:
ACA Health Mandates For Obesity
NOFUSA Health Insurance Covers Obesity
(Here's a little background on the state benefit mandates; not required reading, but if you're interested):
Well, here's the plan that I bought on the exchange; note toward the bottom it lists bariatric surgery as covered, no charge after the deductible, and under the "Limits and Exclusions Apply" popout, it says "Only covered if medically necessary."
Here is what BCBSOK says about medical necessity and bariatric surgery. Note: This is just what BCBS of Oklahoma says in general about bariatric surgery; I haven't been sent this with my policy or anything like that:
Yet in my benefits book, this is what it says concerning bariatric surgery: (on page 48, under exclusions) Note: It's a sample page, but it says the same exact thing in my benefits book.
"For treatment of obesity, including morbid obesity, regardless of the patient's history or diagnosis, including but not limited to the following: weight reduction or dietary control programs; surgical procedures; prescription or nonprescription drugs or medications such as vitamins (whether to be taken orally or by injection), minerals, appetite suppressants, or nutritional supplements; and any complications resulting from weight loss treatments or procedures."
So, Oklahoma has to include bariatric surgery in their plans, mine does, but it's also excluded? What?
I emailed the National Obesity Foundation (the 2nd link I posted) patient advocates to see if they could make heads or tails of this. One of their lawyers got back with me and I sent her all of this information. It's the weekend so I don't know when they'll get back to me.
What do y'all think?
Hi Amanda! I am wanting GS also and I too have only Medicare. I went to a seminar today and was told my upfront was $1670 Surgeon Fee, Approx $600 Hospital Fee and then approx. $1200 Surgery Co pay. I wanted to CRY! They do not offer payment plans but can try and get you financed through a credit company which I am almost positive has sky high interest! I was thinking I would be able to make a promise to pay arrangement, but nope. They said no pay no surgery :(
I live in central tx in the Killeen/Temple area but willing to travel within TX. I have medicare so I'm on a fixed income and a single mom. Has anyone with medicare only had their surgeon let them be billed for the proceedure? Hospital too? Or if you had to pay what was it? I want the GS done hopefully this summer. I turn 40 at the end of the year and I am tired of be the fat hermit who is always at home. I need this 2nd half of my life happy and most of all healthy as my girls leave the nest in the next 2 and 3 years. Thank you so much.
Amanda
I had Aetna. I followed the guidelines exactly and when my surgeon submitted I waited a week and I called them. Now take into account this was 12 years ago, sure things change, but I was told I didn't have 'supervised' exercise program.' I swam daily for those 6 months. As it turns out a lady at the pool was an RN and she wrote a letter saying she saw me daily . I faxed the letter to them. Waited a week and called. I was approved !! Do not give up if denied best of luck it's worth fighting for!
Don't feel too bad - Aetna denied my husband after he jumped through all the hoops because they said his high b/p wasn't a co-morbidity because it was "controlled" with medication. The bariatric surgeone even did a peer-to-peer review with Aetna's medical director and it still got denied.
Aetna is the biggest piece of crap out there right now in the insurance world. Their merger with Coventry has been a DISASTER for policy holders. I work for a major hospital and we are constantly battling with them over claims that get denied in error, claims they refuse to pay in error, etc.
Tracy 5'3" HW: 235 SW: 218 CW: 132 M1: -22 M2: -13 M3: -12 M4: -9 M5: -8 M6: -10 M7: -4
Goal reached in 7 months and 1 week!
Lower Body Lift w/Dr. Barnthouse 7-8-15
Hello Nan, i have aetna insurance and i was denied on 3/11/2015 for a gastric bypass revision. they denied me because i gain weight in the 6mths weight loss requirement program. i cannot exercise because i have a bulge disc in my back. i was told that i could fight against the denial but i don't know what to put in my appeal letter. please help me.
Hockeymom87 · 0 replies · 611 views
