Question:
Not A ?- Exclusion language is sparse in this Aetna US Healthcare policy.

I have Aetna USHealthcare-Basic Health of Washington. I offer this info to assist other fighters. My first referral went to the "network" director and was denied as an exclusion. "We can see that the WLS is medically necessary, we have denied the referral because surgery for obesity is excluded, any treatment for obesity is excluded." In fact, the exclusion reads "obesity treatment; weightloss programs." I've concluded, thanks to the info from Walter Linstrom's web sight (sorry I don't know how to add a link) that obesity doesn't equal morbid obesity and the weightloss programs are not equal to weightloss surgery. The Health Care Authority of Washington State specifically and grossly excludes WLS in another plan it provides (for Public Employees), "medical serivces, drugs, supplies, or surgery (such as but not limited to gastroplasty, gastric stapling, or intestinal bypass) directly related to obesity." It appears that if they had wanted to exclude WLS in the Basic Health Plan they would have written the exclusion in the same manner as the other plan. If the tie always goes to the runner, then I am on first base! I have letters from my orthopedist, OB/GYN, psychiatrist and pulmonary doctors supporting the WLS. I now have to put this information together in some ordered fashion for submission, hopefully by 8-8-99. I will let you know the results and offer info and documents to others if they work!    — Iris T. (posted on August 8, 1999)

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