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Malg22
on 9/21/10 9:54 pm - Tiffin, OH
VSG on 12/18/13
Topic: 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
WASaBubbleButt
on 9/21/10 3:46 am - Mexico
Topic: RE: My ins co won't disclose pre-reqs to me
Which ins co do you have? We might be able to do a few searches and find their policies on line.

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 9/21/10 3:43 am - Mexico
Topic: RE: Cigna "Duration of more than 5 years"???
This one is hard, an appeal could go either way. Have you tried a peer to peer review?

Yes, 30 is obese but most ins co's don't pay until you are morbidly obese.

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 9/21/10 3:41 am - Mexico
Topic: RE: UHC question and help with Insurance!
 
~~Hi everyone for taking the time to read this topic. I am asking for help. Yesterday I went to my first seminar at Dukes in Durham NC. It went great, but when I called my insurance I found out that my insurance wont cover the surgery. UHC said that my job has excluded the surgery from the policy I have :-(  so I ask the Nurse If  I could fill out the application and he said no until I have an answer of approval of my insurance. If not that will be a waste of time, Anyway  UHC told me that I can send a letter to them to appeal it. I dont know where to start of how so I need help writing my first  letter to the insurance to appeal for an approval. If any of you went to the same thing can you please  give me an advice how I can start please??~~

The thing with appeals is that you can appeal anything.  You can have a doctor's order to eat lobster for every single meal but that doesn't mean ins will cover it or that appealing would help. :o(

If you do not have the coverage your appeal would be based on the following, your employer didn't buy the WLS portion but you want WLS anyway.  See what I mean?  Sadly, that isn't going to help.


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 9/21/10 3:38 am - Mexico
Topic: RE: ?Question about Insurance?
I agree with Maria. Just because you'll have ins that does not mean they will cover bariatrics.

If it does cover bariatrics each plan is different on their requirements.

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 9/21/10 3:31 am - Mexico
Topic: RE: BCBS Georgia
Did you know that MOST people do not have bariatric coverage? It's expensive. The above poster is right.

If you do not have another ins plan to choose from you are left with self pay.

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 9/21/10 3:26 am - Mexico
Topic: RE: Not fat enough now....
They are not permitted to do this. Your starting BMI is what matters. This one should be an easy peasy appeal.

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 9/21/10 3:23 am - Mexico
Topic: RE: Walmart BCBS WLS Exclusion / Other Options?
Maybe do what I did. Go to Mexico. Smaller loans are easier to get than larger loans.

The problem with your ins is that you likely have a plan through your employer. If they do not pay an additional premium for WLS, it isn't going to be covered. Perhaps go to your employer and ask them to add this? Don't bank on it happening because it's expensive and they can't just get you covered, it would be the entire company.

Previously Midwesterngirl

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

See  my blog for newbies: 
http://wasabubblebutt.blogspot.com/
Jennifer M.
on 9/20/10 2:03 pm
Topic: RE: Waiting...appeal vs pre-cert... Aetna
Why were you originally denied?
BurberryBenz
on 9/20/10 12:31 pm, edited 9/20/10 1:28 pm
Topic: Walmart BCBS WLS Exclusion / Other Options?

Hello, just a little background info on me first.

I am 23, female. 5'9", 360lbs. Size 22/24. BMI of 53.X. 

I have gained 180lbs in the past 8 years. I've had thyroid testing twice, that's not the problem. 

I tried gym/home dieting from 2005-2006. I've tried medically assisted weight loss 3 times with one facility between 2006-2007. I tried Medi-Fast in 2007. I tried Metabolic Research Center for 4 months in 2008. I talked to a psychologist re: emotional eating for 6 months in 2008. I tried hypnosis in 2009. I then tried medically-assisted weight loss in 2009 for a few months again. I also tried the HCG fad in 2010. I then got a dietitian in 2010. I've lost, at a most, 15lbs, but put it all back on and then some. I've been on prescription drugs for anxiety/depression due to this personal failure since 2005.

I don't have diabetes, high blood pressure, high cholesterol. I do have depression, anxiety, skin problems, and underwent a sleep study and was diagnosed with sleep apnea this year. I sleep with a CPAP machine. I do it faithfully as I know without it, I will fall asleep throughout the day. But because of my extremely sensitive skin, I have switched facial masks 3 times, but I am getting horrible skin reactions on my face from it. I have put fabric barriers over the plastic pieces to stop irritating my skin, but my skin is still irritated and I've had to purchase very expensive creams for my skin to relieve the irritations as they are the only things that work.

My gynecologist referred me to a bariatric surgeon two weeks ago. I went to a seminar that outlines the obesity information, types of surgeries performed, etc. 

It all sounds great. I'd like to proceed with a RNY Gastric Bypass. However, my insurance is with BCBS Arkansas Advantage and it specifically excludes any type of weight loss treatment, surgery, medication, etc. for obesity and morbid obesity.

My insurance company is so ridiculous that when I went to the doctor for my depression, when the doctor had put one of my diagnosis as "obesity" (which he always does?); the insurance company denied the bill. Citing they do not cover charges relating to obesity. I wrote a letter back informing them that 33% of people in my state are obese and if every one of their bills was denied simply for the fact they were overweight, then they should be informed of such when they were accepted as a member and their money should be refunded. They paid the bill.

So, therein lies the problem.

1. My insurance doesn't cover the surgery.

2. I applied for a loan through CareCredit to self-pay for the SX ($18,500 inclusive of surgeon/anes/asst. surgeon/pathology/OP facility). I was denied. (Probably because I have two car loans.)

3. I don't have a house to refinance to get extra money?

4. What can I do now? What are my options?

 

Thanks.  :)

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