Recent Posts

Nan2008
on 9/27/10 4:55 am - Midland, MI
Topic: RE: Super Freaked out and nervous!

It is TOTALLY worth it.  I was denied for surgery because my surgeon's office submitted my paperwork to soon.  I too was doing their 3 month multidisciplinary program.  My surgeon's office submited the paperwork thinking I had completed it with my PCP.  I had not and was denied.  I finished the 3 month MD program, appealed, and won.  I had surgery in March 09 and have lost 160 lbs.

A friend of mine was denied by Aetna also.  Reason being 'lack of proof of obesity for 2 years'.  I helped her with her appeal and she was approved and had surgery in Jan 2010.

My daughter was also denied.  I appealed for her, and she won!  Had surgery this past May and is down 78.5 pounds.

So yes, it can be quite discouraging to hear all the stories of how Aetna is so hard to get approved, but basically, if you meet all of their requirements in their clinical bulletin 0157 (I'm assuming you have that already) you will get approved.  You just have to make sure all of your T's are crossed and your I's are dotted!  And if you are denied, get the reason why, and prove to them what they need to see.

One thing to keep in mind, it is not a 12 week program according to one of the Aetna appeals team member's I talked to.  It is a 90 day multidisciplinary program.  The wording when I was getting approved said 3 month multidisciplinary program.  He said this means 90 days!!  No less or you will get denied.  So make sure your first appoint and your last appointment with your PCP are at least 90 days apart!

I will PM you if you'd like a breakdown of everything I did to get approved.  Also, when talking to the Aetna representative, they stated the importance of the 'behavior modification' and that being documented with your PCP.  So make sure you are meeting all of the requirments as stated in the 0157 bulletin.

Good Luck to you!

Nan

Nan

HW 300
/ SW 280 / CW 138 /
GW 140
Hit Goal 4/2/2010

        
mrsconrad
on 9/27/10 4:48 am - Steger, IL
Topic: HOW DOES "SELF INSURED" affect approval
I have Aetna, but my company is self insured... does anyone know how this impacts or affects the approval process
mrsconrad
on 9/27/10 4:46 am - Steger, IL
Topic: RE: DENIED BY AETNA ON APPEAL
Well, went back to the doctors today, so that I can get another months worth of phydician supervised diet on the books, just trying to do anything I can to continue to gain the paperwork neeed.  I am trying to keep my chin up - but its not easy.  As I do not have the letter, I cant tell what the denial is for, but I will wait for the mail and as soon as I begin in, do the next steps.

My company is self insured, so I am not sure how that is playing in - so I am trying to investigate that...

thanks for all the well wishes!

Maria
Nan2008
on 9/27/10 4:45 am - Midland, MI
Topic: RE: DENIED BY AETNA ON APPEAL
When you get the denial letter in the mail, let me know what it says.  My daughter's as well as my friend's denial letter stated 'lack of proof of 2 years of being obese."  Could that be it?  It sounds like all the other requirements are met.  I'm pretty familiar with Aetna's requirements because my daughter and I were denied, then approved in appeal.  A friend of mine was denied and I helped her with her appeal, and she got approved.  My son's documentation is with Aetna as of last week and we are waiting on an approval for his surgery!!  I feel your pain because I have been there.  But don't give up!! 

Once you get the denial letter, let us know what it says and I can certainly forward you the appeal letters I used for all of our appeals.

Nan

Nan

HW 300
/ SW 280 / CW 138 /
GW 140
Hit Goal 4/2/2010

        
moving-on
on 9/27/10 2:33 am - Rimrock, AZ
Topic: RE: DENIED BY AETNA ON APPEAL
They really had no valid reason.  Said they didnt receive some my labs and didnt see that i was on Statins.  My Dr sent over 106 pages and was very thorough.  The surgeon says they are just trying yank my chains it sounds like.  Pretty frustrating as I am ready to be on the losers bench.
Moving on to better health        
KimberlyHeidi
on 9/26/10 9:34 am - VA
Topic: RE: Buy insurance to get WLS or Self pay??

If I sign up for my husbands insurance (excludes all things having to due with weight) sign up is next month but it doesnt go into effect to the first of the year. What if I had WLS before the first of the year but after I signed up for his insurance?

WASaBubbleButt
on 9/26/10 9:21 am - Mexico
Topic: RE: Empire Blue Cross Blue Shield says VSG is still Experimental????
BC/BS is the hardest for appeals on that specific issue, investigational. Some just flat out refuse to pay for it, a few have won through appeal.

VSG is not investigational anymore, not sure why they play these games.

You have nothing to lose by trying. You can go to the ASMBS site and obtain proof there that it is not investigational. Then find a few peer reviewed studies showing that weight loss is superior to a band and safer than a sleeve.

Fight to the bitter end.

Previously Midwesterngirl

The band got me to goal, the sleeve will keep me there.

See  my blog for newbies: 
http://wasabubblebutt.blogspot.com/
WASaBubbleButt
on 9/26/10 9:18 am - Mexico
Topic: RE: Buy insurance to get WLS or Self pay??
On September 24, 2010 at 10:55 AM Pacific Time, KimberlyHeidi wrote:
I am unsure of what to do. I have tried to get insurance before but because of my issues I have been denied. 

The last few surgeons I have spoken with would like me to get insurance before surgery as a back up. I am not sure what to do since I have been denied in the past. 

It's a double edge sword.  You can't get a private plan when you are obese and then you won't be able to get a private plan after you have WLS for about 5 years.  You are out of luck on that one.

I'm still going to suggest Mexico.  Research is free, surgery in the US is double the cost.  With proper research it's safe.  Shopping by price gets you less than skilled surgeons.


Previously Midwesterngirl

The band got me to goal, the sleeve will keep me there.

See  my blog for newbies: 
http://wasabubblebutt.blogspot.com/
WASaBubbleButt
on 9/26/10 9:15 am - Mexico
Topic: RE: Please read and give me advice!
 
You can hire an attorney... Walter someone, I forget.  PM me if you want and I'll get his name.  He specializes in this.

You can go through the Ins Commissioner in your state. 

She can't do this, it's against the law.


Previously Midwesterngirl

The band got me to goal, the sleeve will keep me there.

See  my blog for newbies: 
http://wasabubblebutt.blogspot.com/
WASaBubbleButt
on 9/26/10 9:12 am - Mexico
Topic: RE: DENIED BY AETNA ON APPEAL
On September 25, 2010 at 8:05 PM Pacific Time, moving-on wrote:
I so feel your pain.  I am going through the same thing.  I had the rug pulled out from me.  My surgeons office calls me and says I was approved, I do all the pre-op testing and they start me on a liquid diet.  I am on liquids for a week and then get a letter from my insurance saying they are denying my surgery.  Oh boy was i depressed.  My surgeons office does a peer to peer and an appeal and it was denied as well.  I just sent in a request for a Fair Hearing on Wed and am waiting myself to see what is going to happen next.  I have a BMI of 42, diabetic, sleep apnea, high cholesterol, high blood pressure, so I am well qualified as yourself.  I found a copy of a letter on this site and I used it.  Hoping that it works for me as i have seen it work for others.  My Health Advocate states there is a law stating that they cannot deny us, not sure how to make that work.  I wish you the best of luck and we will have to stick together to succeed.  I will not quit either.  
 
What was the reason for the denial?


Previously Midwesterngirl

The band got me to goal, the sleeve will keep me there.

See  my blog for newbies: 
http://wasabubblebutt.blogspot.com/
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