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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
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
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
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?
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.
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
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.
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
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.
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
What was the reason for the denial?
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/