Hello there. I have recently "completed" or so I had thought the necessary requirements from Aetna to be approved for a the gastric sleeve surgery. I finished my classes at Ohio State Medical Center on July 27th. In 2011 and 2012 I did not take any trips to the doctor, I travel for work so because my last visit was in 2010 I was denied due to not having 2 consecutive years of proof of obesity. I was hoping to get some suggestions on what I can do in this situation. Thank you so much for taking the time to read this.

 

Sincerely,

Justin Tuttle

I don't have any answer because I am in the same boat.  I am hoping you get some responses here.  

Hi! Ok I'm feeling confused as to what to do next! Here's my story.... I had an old style VGB(the kind they do not perform anymore) 27 years ago. I had regained my weight many years ago. This last year I have had lots of problems GERD, Hiatal hernia, severe pain and distention, vomiting and nausea, increasing back and hip problems. Went to my reg GI Dr and he did an emptying test and basically said fluids are passing but solids are causing problems. So he sent me to Dr Kroh for further testing which was done at the Cleveland Clinic. After having those tests performed he sent me back to my reg GI Dr. I saw him yesterday and was so frustrated and upset afterwards. Basically he said those tests showed the same thing.......narrowing around the site of the band (again) and bad gastritis. He said there was nothing he could do so I just need to learn to live with it!! He said I just have to push lots of liquids after I do eat a meal...even if it takes days of liquids...till everything passes!! Also eat soft, easily digested foods that will pass easily! (Yeah that's been my life for how long...trying not too eat much veggies, fruit, meat...wonder why I can't lose weight??) I told him I wanted to have the band removed and he said "well that will only cause you to GAIN more weight!" I explained to him that obviously the band isn't really working and only causing me MORE problems when I do try to diet and lose weight! So he suggested I called Dr Kroh back!! Shhhheez...back to square one! I did so and they scheduled me for an appt Nov 18th and said they checked mi insurance and it does not cover any Bariatric surgery but to come in for my appt ant they would write up an appeal to the ins co. Because of my medical issues. Then she told me not to get my hopes up because they are almost always denied! I then asked her about the DS surgery and she knew nothing about it! (??) She said they would appeal for a band removal into a RNY! Now here are my questions........
-What do I do now??
-Should I let them continue with the appeal?? And is that appeal specific to only that Dr and the RNY??
-Or do I try to find a DS surgeon that does revisions?? And HOW do I do that??
-And is the DS harder to get approved then the RNY??
-Also do I let the Dr appeal or go thru an ADVOCATE myself...or both??
Sorry foy the loooong post and all the questions....just don't know what to do next?? Thanks....DIANE

I read that on kentucky medicaid's alternative benefit plan, which is the new expansion, that bariatric surgery is not covered starting 2014......hope its not true!

I have been denied twice by Cigna. First was because the In-Network doctor submitted a claim to a non network facility.  We got that straighten out.  Now Cigna has come back again to say I was denied me for the sleeve for the following reasons:

They say medical necessity has not been established because:

1. The documentation submitted does not confirm that technical failure has been demonstrated on upper GI and EGD.

2. the documentation submitted does not confirm that due to technical failure of the original bariatric surgical procedure you have failed to achieve adequate weight loss as defined above at the least 2 years following original surgery (I had the lapband surgery that never worked for me)

3. The documentation submitted does not confirm that you have remained fully compliant with the medically prescribed postoperative nutrition and exercise program.

The doctor is going to attempt a peer to peer review, should I do anything else?  The lapband didn't work for me.  I have high blood pressure, my PCP submitted a report showing my heart is affected by the high blood pressure.  I have tried everything imaginable to try to lose weight and I can't keep it off.  I even bought a dog to walk only to find that I could walk about couple of blocks before hip started to hurt and feet went numb.  I just don't know what to do at this point.

If someone could guide me so I can get approved.

 

Thank you!

 

Gigi