Question:
Support Needed, Insurance has denied request for revision

Aetna Just Turned Down Surgeon's Request for a Revision. My original surgery was 21 months ago; it was a Lap RNY/transected. I started at nearly 500 lbs, with a BMI into the 80s. My surgeon wanted to be conservative at the time, so only 100 cms were bypassed. I was fine with this, as I should prefer someones erring on the side of caution. At the time and since, we discussed that if this amount seemed inadequate because of my high starting weight, he'd be willing to go back in and revise. Ever since the summer, I have stablized at about 150 lbs for a total loss. I have 200 more to go. I'm consistently doing the right things; high protein, high water consumption, watching fats, sugar, and calories in general. I'm more active than I've been in over a dozen years, in spite of diagnosed plantar faciitis/heel spurs (both feet) as well as severe, degenerative arthritis diagnosed seven years ago in both knees. My surgeon has already had an upper GI series performed on me, and says the pouch is just the size it should be at this point. I have been working with the dieticians all along as well. Because of all of this, my surgeon was ready to do a revision. We have COBRA now through my husband's former employer...who changed insurance companies a few months ago from Blue Cross to Aetna. A phone message was left yesterday for my surgeon from a physician at Aetna, saying that the revision request was denied. We had already sent them several years worth of records, and so had my PCP. They are taking the view that because nothing went "wrong" mechanically with the surgery, a revision is not in order. The other comment made was that I didn't have a documented exercise program nor, I'm not kidding, two years worth of food diaries listed in my PCP's files. How many people or physicians keep or ask patients to keep two year food diaries, let alone put all that info in their charts? Regarding an exercise regime, this is the same company that previously turned down requests for foot and knee surgeries to help me become more mobile. The reason? I was morbidly obese and would only continue to do more damage! This to me is trying to have it both ways. More illogical that anything else, though, is that I still fit their own criteria for WLS as a first-time patient! A further stress is that we are fighting my husband's COBRA administrator. We feel that because I am registered disabled by Social Security, COBRA law states that we are entitled to another 11 months of coverage. The administrator is arguing that because we didn't let them know within 60 days of coverage (We did; it was a different COBRA administrator then), they have the right to cut us off at the end of this month and have given no indication when they plan to rule on our request. So...I feel like I'm playing a game of "Beat the Clock" as well. I apologize for how long this posting has become; I have attempted to offer support in this forum for the past two years, and have received wonderful support and feedback myself. I could surely use some of that now! = ) Thank you so much.    — CaseyinLA (posted on March 11, 2003)

March 11, 2003
Additional by-pass may not be the answer. I am on the Yahoo graduates board, and even with a 150 to 200 cm by pass, manny have the same proble. One suggestion: my daughter does water arobics at the Y. Good workout, no joint stress. Another successful strategy has been cold turkey on the carbs. Go to all protein for a few days. Use fitday.com and honestly record your eating. Also you said your pouch was fine, what about the stoma. Has it stretched. This is just my 2 cents.
   — faybay

March 11, 2003
You need to appeal their decision in writing, sent certified. Go above the immediate person. Keep appealing all decisions. It will push you up to the next level. Secondly, you will probably need a lawyer. If money is an issue, look for the legal assistance foundation or call the bar association and request a pro bono lawyer. find a legal assistance
   — Marian B.

March 11, 2003
If your Dr. feels you need this revision you might want to contact Walter Lindstrom for your appeal. I have Aetna also and came real close to contacting him myself when I finally receved my approval this week. Go to www.walterlindstrom.com or click onto the legal portion of this site. I'm sure he can help especially since time is of the essence. GOOD LUCK!!
   — Barbara S.

March 11, 2003
I wish you all the best with whatever option you choose to achieve your weightloss goal. I'm writing more in response to your insurance issues. Since Cobra is something you must pay for yourself, is it possible to find out what date your first payment was made? This is all paperwork they must retain so there has to be some documentation someplace. Were you notified of your COBRA options in a timely manner to begin with?
   — Diane S.

March 13, 2003
I'm the original poster. I want to thank everyone who offered support and suggestions. I'm putting together a formal, written appeal as well as contacting my PCP to write a letter for the appeal. I was never told about the size of the stoma, so an endoscopy may be necessary as well. There has been a bit of good news since my last posting. We contacted the company that administers my husband's COBRA benefits; because of my long-term disability, we have been given 11 more months of coverage. At least now there is a bit more time to work with. Thanks again, everyone! Further support/prayers/good thoughts always welcome! = )
   — CaseyinLA