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Topic: RE: Denied (Again)
i would definitely get my surgeon to perform upper GI as it seems from their letter they need proof other than inadequate weight loss of problems. i actually told my surgeon we needed to do that before we submitted for revsion (i had vbg) and he declined; guess what.. i got declined (after they approved me verbally). good luck!
Topic: RE: Surgery this month or wait till Jan?
if you get an approval.. how long is it good for? also, you should get plenty of notice on what your insurance will or will not be before january (we got our paperwork in today for next year to review policies/options).
i personally would not risk loosing my wls & waiting until january. good luck!
i personally would not risk loosing my wls & waiting until january. good luck!
Topic: AETNA approved then denied. any help appreciated
Aetna approved me verbally, then sent denial letter for revision. Their reasons are because (1)6 mos diet and/or (2) 3 mos multi behavioral surgery prep. My surgeon is trying to get peer to peer.. they have granted it but playing phone tag. In the meantime, I went to website and this is what I found re: revision. My question is.. is does NOT state for revision the above is required. Anyone have any tips on appealing this or what I should do. I had original VBG in 1998 - lost about 80 lbs gained it back plus 50. Current BMI is 47; high blood pressure; high cholesterol, (meds for all as of 3 weeks ago); and my PCP decided to not treat for diabetes because I was having WLS this month (this was before Aetna took back their approval) Thanks for your help.
Repeat Bariatric Surgery:
Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction, stricture, erosion, or band slippage.
Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:
- Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
- Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
-
Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments.
Topic: Surgery this month or wait till Jan?
Ok so it's taken about a year to get everything I need together - the only thing I need is 1 more PCP office visit to complete my 6 months of diet/exercise documentation and then a nut eval and psych eval (which I HOPE I can get done this month!)
ANYWAY...I know the "no brainer" answer BUT I am going to throw my question out there anyway...
Soooooo I (like many others nowadays) am on a strict budget. If I can get approved for my surgery by the end of this month, I will owe about $4000 upon check in at the hospital. Anyone know if this has to be paid in full? My surgeon's office told most people do a partial payment and then smaller payments to pay it off. If this is the case I want this surgery ASAP but how much would/should I have in hand to apply toward my deductible on the day of surgery?
MY "worse case senerio" my insurance is either going away fully OR it's going to be much better...by that I mean that beginning in Jan it would only be $1500 deductible and I would be able to get FSA (Flexible spending account) to cover it.
I won't know till end of the month which "worse case" - as that is when enrollment and contracts will be finalized.
I know waiting till Jan would be the smarter move financially but scared if I wait it won't be the option I get delt. ANY ADVISE?
ANYWAY...I know the "no brainer" answer BUT I am going to throw my question out there anyway...
Soooooo I (like many others nowadays) am on a strict budget. If I can get approved for my surgery by the end of this month, I will owe about $4000 upon check in at the hospital. Anyone know if this has to be paid in full? My surgeon's office told most people do a partial payment and then smaller payments to pay it off. If this is the case I want this surgery ASAP but how much would/should I have in hand to apply toward my deductible on the day of surgery?
MY "worse case senerio" my insurance is either going away fully OR it's going to be much better...by that I mean that beginning in Jan it would only be $1500 deductible and I would be able to get FSA (Flexible spending account) to cover it.
I won't know till end of the month which "worse case" - as that is when enrollment and contracts will be finalized.
I know waiting till Jan would be the smarter move financially but scared if I wait it won't be the option I get delt. ANY ADVISE?
Topic: RE: How did you do your 6 mo. of medically supervised WL if your insurance required it?
Nan, did you have to do 6 mos medically supervised plus 3 mos multidisciplinary program?
Topic: RE: Updates on Aetna Appeal Denial/Peer to Peer question
why did they deny you again? if you met their criteria after their initial denial? what was the reason?
Topic: Denied (Again)
Well, I got my letter back from the insurance company today and my appeal was denied. Here are some of the details from the letter:
"Over Grievance and Appeal medical director, a pediatric critical care physican, Victor N. Blankson, MD KY license # . . . . in conjunction with an external independent reviewer specializing in general surgery and bariatric surgery, Julie Kim, MD, Mass. license # .... thoroughly reviewed the following information: written appeal request, notificaiton of denial issued by Active Health Management, Active Health Management criteria, medical records from Centennial Bariatrics.
We were unable to approve the requested bariatric surgery revision on October 4, 2010 because there are not any documented complications of the Laparoscopic Gastric Banding procedure performed in 2009. . . .As a result you do not meet plan criteria for revision or repeat bariatric surgery, from the Laparoscopic Gastric Banding to the Duodenal Switch, at this time."
So, any suggestions on what to write in my request for the Independent External Review?
Also, I am going to call somebody, either my PCP , or find a GI doc and see about getting an upper GI done.
"Over Grievance and Appeal medical director, a pediatric critical care physican, Victor N. Blankson, MD KY license # . . . . in conjunction with an external independent reviewer specializing in general surgery and bariatric surgery, Julie Kim, MD, Mass. license # .... thoroughly reviewed the following information: written appeal request, notificaiton of denial issued by Active Health Management, Active Health Management criteria, medical records from Centennial Bariatrics.
We were unable to approve the requested bariatric surgery revision on October 4, 2010 because there are not any documented complications of the Laparoscopic Gastric Banding procedure performed in 2009. . . .As a result you do not meet plan criteria for revision or repeat bariatric surgery, from the Laparoscopic Gastric Banding to the Duodenal Switch, at this time."
So, any suggestions on what to write in my request for the Independent External Review?
Also, I am going to call somebody, either my PCP , or find a GI doc and see about getting an upper GI done.
Highest Weight: 564 / Post Band Pre DS Weight: 508 / Surgey Date Weight: 449
Current Weight: 209 / Goal Weight: 150 (BMI of 25).
Topic: RE: Lost Insurance
That's another problem I have, lack of money, I called the Dr this morning and left a message hopefully we can work things out...when it rains it pours... =/
Topic: RE: Lost Insurance
Is it possible for you to self pay for the fills? My friend had the Lap Band and is a self pay. I think she was telling me her fills were $125 or something like that??
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
Topic: Lost Insurance
I lost my insurance now what do I do? Had lap-band 2006 haven't gone in to get adjusted in a long time...starting to gain weight back.....very depressed...HELP!!!! Any ideas?
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