| Blue Cross Blue Shield Federal Basic |
|---|
| Insurer Policy |
Blue Cross Blue Shield Federal Basic |
| Insurer Status | Approved after first letter (08/20/05) |
| Surgery Type |
Laparoscopic RNY |
| Source |
Deborah T |
| MEDICARE - TX |
|---|
| Insurer Policy |
MEDICARE - TX |
| Insurer Status | Approved after first letter (08/13/05) |
| Surgery Type |
Laparoscopic RNY |
| Pre-Op BMI |
47.9 |
| MD-supervised programs |
2 (56 weeks) |
| Comorbidities |
Arthritis, Dibetic, Hypertension, Gout, Knee & Back pain, etc. |
| Policy |
Must be medically necessary |
| Comments |
Because I am disabled (even at the age of 43) I have a number of Co-morbidities so it was very easy to see that this procedure was more than medically necessary. I was pre-approved for the surgery before I had even found a doctor to do the precedure. Finding a surgeon that would take Medicare was the problem not getting an approval from Medicare. |
| Source |
Lora Ann T |
| aag |
|---|
| Insurer Policy |
aag (health smart) |
| Insurer Status | (06/17/03) |
| Source |
Susan S |
| Insurer Policy |
aag (not sure) |
| Insurer Status | First letter sent - still waiting (06/18/03) |
| Source |
Susan S |
| Insurer Policy |
AAG |
| Insurer Status | First letter sent - still waiting |
| Surgery Type |
Lap Band |
| Pre-Op BMI |
43.7 |
| MD-supervised programs |
2 (68 weeks) |
| Comorbidities |
GERD, Obesity hypoventilation syndrome |
| Source |
Edward U |
| Access |
|---|
| Insurer Policy |
Access (PPO) |
| Insurer Status | Approved after first letter (05/19/05) |
| Surgery Type |
Laparoscopic RNY - distal |
| Pre-Op BMI |
47.7 |
| Source |
Rosa G |
| Insurer Policy |
ACCESS |
| Insurer Status | Approved after first letter (12/08/05) |
| Surgery Type |
Laparoscopic RNY |
| Comorbidities |
Arthritis, Depression |
| Source |
Johnny S |
| Insurer Policy |
Access |
| Insurer Status | Approved after first letter (04/01/06) |
| Comorbidities |
none |
| Policy |
Don't know |
| Comments |
Very easy.. no problems encountered. |
| Source |
Eyness R |
| Access Admin. |
|---|
| Insurer Policy |
Access Admin. (PPO) |
| Insurer Status | Approved after first letter (06/15/05) |
| Surgery Type |
Laparoscopic RNY - proximal |
| Pre-Op BMI |
46.6 |
| Source |
Margie M |
| Access Administrators |
|---|
| Insurer Policy |
Access Administrators (PPO) |
| Insurer Status | Approved after first letter (08/18/05) |
| Surgery Type |
Laparoscopic RNY |
| Pre-Op BMI |
43.0 |
| Source |
Joe B |
| Access Medical |
|---|
| Insurer Policy |
Access Medical (Ysleta ISD) |
| Insurer Status | Approved after first letter (11/21/99) |
| Surgery Type |
Laparoscopic RNY |
| Weeks to approval |
6 |
| Pre-Op BMI |
52.3 |
| MD-supervised programs |
4 (44 weeks) |
| Policy |
Must be medically necessary |
| Source |
Heidi J |
| Insurer Policy |
Access Medical (County of El Paso) |
| Insurer Status | Denied after appeal letter (08/28/02) |
| MD-supervised programs |
2 (60 weeks) |
| Comorbidities |
hypertension, borderline diabetic, joint and back pain,gallstones |
| Policy |
Written exclusion policy |
| Comments |
I called the Bariatric Center in El Paso and spoke to one of the coordinators of this procedure. She did state that she KNEW that Access for City Employees did not cover the procedure. She took down our insurance information and my information and stated she would call them and then call me back to advise. My husband has insurance with Access through the County of El Paso and when the coordinator called me back (a few minutes later), she advised that this IS a covered benefit under this insurance. I have been scheduled for the first consultation next month!!!!
3-19-02 Got a call from the Bariatric Center in El Paso. Unfortunately, upon checking again with our insurance, they were told that it WOULD NOT be covered. Access with the City and County will not cover this procedure and they do not want to be bothered for this because they will not budge on this decision. Filing an appeal will not change their decision.
3-27-02 After much thought and reading all the other exclusions and asking for advice from this wonderful website, I have decided that I AM NOT going to let an "exclusion" stop me!! I am going to try to get this approved with my primary physican's help. If the bariatric center won't help me, well I will do it myself. I will update and post what happens for anyone else having the same problem I am with this insurance.
04/01/02 Sent off my first appeal letter to Access County of El Paso. Called first to get name of Plan Administrator and addressed the letter specifically to her. Letter was sent certified, return receipt. Now lets see how long it takes before I get any kind of answer.
4/09/02 Still haven't heard from my insurance so I called the plan administrator. I was transferred to her and she knew what I was calling about after I identified myself. She admitted that she had the paperwork on her desk, but that she had not had the chance to review it. She asked me to give her till tomorrow to go over it and then she would contact me about it. I guess I should have just gotten on the phone the very next day after receiving the return receipt, but I was trying to be nice and give her a chance to review it. Well, from now on, I will keep at them if I don't get an answer from her tomorrow as requested.
4/15/02 Had to keep calling insurance company to get an answer. Had been asked by plan administrator for one more day to review paperwork and she would call back very next day. Very next day turned into 3 and then was denied due to exclusion and obesity and morbid obesity being "same thing" according to them. Started process on next step (benefits coordinator) and was told I would NOT be approved because of exclusion WITHOUT EVEN HAVING ANY OF MY PAPERWORK TO REVIEW. Reminded them about medical necessity in the policy, said they'd need letter from my doctor. Advised her it was at insurance company with plan administrator. She called back a few minutes later and stated that doctor's letter said obesity, not morbid obesity. Told her I'd have letter re-written. Looks like they are going to start nit-picking through my paperwork now to see what else they can deny me on. Seeking legal advice.
4/22/02 Was told by plan administrator that I would receive my denial letter in the mail "next week". "Next week" has come and gone and still no denial letter. Called her today to find out when I would be getting the letter only to be told "she is out of the building." Seems like everytime I call for her she is "on another line" or "out of the building." Leaving messages does not help. Spoke to her supervisor today and was told she would look into it to see what is going on and that she would "call me back." She didn't say when, so I guess I shouldn't say that I haven't received the call back yet.
4-23-02 Wrote letter to director of human resources to appeal denial and to complain about his benefits coordinator making a decision about my appeal without having any of my paperwork in front of her.
4-24-02 Called benefits coordinator to request postponing presenting my appeal to Baord until June instead of May due to my having retained Walter Lindstrom for help.
Didn't answer, left voice mail message for her to call me.
4-25-02 FINALLY received denial letter from insurance company. Took calling 3 times!!!
Benefits coordinator returned my call and let me know that my paperwork will be requested from insurance company for preparation for Board meeting May 17th. Wanted to let me know they had paperwork I sent to director and are "on top" of situation. I then asked for postponement of presentation of paperwork to Board until June because of contacting a lawyer to help. Was advised the director would need to be consulted and would get back to me of decision.
4-29-02 Called benefits coordinator to find out if my paperwork would be postponed till June's Board meeting. She advised that it would and asked if I needed their response in writing. Stated I did. It is now 5-3 and have not received anything yet. Seems like I have to keep calling them to get what they say they will send in writing.
5-1-02 Sent all materials requested priority mail to Walter Lindstrom for help. Hopefully, he will still be able to help once he has had the opportunity to review my materials. Anxiously awaiting a response.
6-3-02 Spoke with Kelly Lindstrom. Advised that appeal will be faxed to human resources office tomorrow and that they would be contacting benefits personnel. Will mail hard copy of appeal to me and will be contacting me soon to advise what I need to do to be ready for my appeal before the Board. Will be on conference call during meeting to monitor what goes on at meeting.
6-19-02 Finally had appeal heard by the Board. Walter Lindstrom was ABSOLUTELY AWESOME in presenting my case. Unfortunately, we are still in the "wait and see" stage. Chair of the Board advised that they may not have an answer for us soon because they still wanted to discuss the matter further and needed more information. Mr. Lindstrom kindly requested that they fax their decision to him as soon as it is made so that we can proceed. There may not be a decision until the next Board meeting next month. I just hope that Mr. Lindstrom's presentation is all they need to make the RIGHT decision. However, whatever the answer, I recommend Mr. Lindstrom highly to anyone having trouble getting their insurance company approving the surgery.
6-25-02 Received a cc: certified letter from director of human resources advising that the Board had returned my paperwork to the insurance company requiring them to obtain all medical records pertaining to my request for surgery and then have their "Utilization Mangement Department" perform a thorough review and then submit all documentation and findings to the Board for its determination of my appeal. Seems like they should have done this when I first appealed their denial of pre-certification. I firmly believe that if I had not retained the services of Walter Lindstrom for his help with my second appeal, this would not be happening!!! I guess that I will have to wait for the next Board meeting for an answer.
09/10/02 Well, I got the SECOND DENIAL letter from the Board on 09/05. They are upholding the denial sticking to their exclusion which does NOT address MORBID OBESITY OR THE SURGERY ITSELF!!! I can't believe that they are sticking by that exclusion!!! Especially after the way Walter blasted them with the STRONG appeal he delivered for me. Just waiting for the next step now.
09/17/02 Spoke with Kelley Brown Lindstrom and she advised that the appeal Walter handled for me with the Board was our FINAL appeal. Unless we want to sue, ther are no other options left. Don't believe we want to go that route. Guess there is nothing else to do expect consider doing self pay.
09-06-03 Well, here I am again. This time I have health insurance thru my employer, the City of El Paso-Access. This time, I KNOW that they have elected to offer coverage for the surgery to employees. In talking to Lori at the bariatric center today, she informed me that they are beginning to make it harder for employees to have this surgery approved. In talking with her, it seems that I have all I need to be approved. I have an appointment with the bariatric center on Nov. 10th. I will take with me all the records I have at my disposal and hopefully, I will be able to move to the next step to be on my way to the "other side" soon. Please say a prayer for me and keep your fingers crossed. Like everyone who has had and wants this surgery, I feel like it is the only way I will finally win the battle with my weight. Will post again after my appointment on the 10th of November. |
| Source |
Mari T |
| Insurer Policy |
Access Medical |
| Insurer Status | Approved after appeal letter (05/28/2003) |
| Surgery Type |
Laparoscopic RNY |
| Weeks to approval |
1 |
| Pre-Op BMI |
54.9 |
| Comorbidities |
Sleep apnea, GERD, Arthritis. Diabetes |
| Policy |
Must be medically necessary |
| Comments |
It wasn't the insurance that gave me a problem, it was my employer. |
| Source |
Julie W |
| Insurer Policy |
Access Medical (PPO) |
| Insurer Status | Approved after first letter (05/08/03) |
| Surgery Type |
Laparoscopic RNY |
| Comorbidities |
Diabetes, Hypertension, Cholesterol |
| Policy |
Don't know |
| Comments |
I had already done my paperwork and had my psychiatric evaluation. I have been searching into different websites and getting all excited about it. I could already imagine myself without diabetes, no high blood pressure or at least have it under control, just feeling better and finally slimming myself down, which has always been a dream. Supposedly there are new requisitions that took effect on January 2003 and it brought me back to step 1, now I have to be in a weight loss program and exercise program, quite a surprise for me. Providence Bariatric does not know of any changes and my insurance company advised me that they do not have to advise them of any changes. I feel like a child and being told to loose weight and exercise, not taking into consideration my medical problems, what a disappointment. I'm trying not to get myself down, so time will tell what will happen.
9/6/04
No advance in my paperwork, can't seem to move forward. My insurance company is requesting info on some classes I took at the beginning of the year and my doctor just doesn't provide what's needed. 1st request was sent to her in May....... I have to go on insulin but I'm trying to hold off, trying to eat better but I guess I have no choice.... oh well!!! I still have hope.. Tata for now!!! |
| Source |
Cecilia B |
| Insurer Policy |
Access Medical |
| Insurer Status | Approved after first letter (07/11/03) |
| Surgery Type |
Laparoscopic RNY |
| Pre-Op BMI |
41.6 |
| Source |
Jessica J |
| Insurer Policy |
Access Medical |
| Insurer Status | First letter sent - still waiting (08/20/03) |
| Source |
Sylvia M |
| Insurer Policy |
Access Medical (PPO) |
| Insurer Status | Approved after 2nd appeal letter (04/20/04) |
| Surgery Type |
Laparoscopic RNY |
| Pre-Op BMI |
52.7 |
| Source |
Coleen S |
| Insurer Policy |
Access Medical (PPO) |
| Insurer Status | Approved after first letter (03/04/05) |
| Surgery Type |
Laparoscopic RNY - proximal |
| Weeks to approval |
4 |
| Pre-Op BMI |
46.3 |
| Comorbidities |
infertility, hypothyroidism, prediabetic, uterine hyperplasia |
| Policy |
Must be medically necessary |
| Comments |
Where do I start? They are doing all they can to make it impossible to be approved. We have been to a 6 month Dr. Supervised program for weight loss, and during that time we also went to a class name little changes big results a nutrition and lifestyle class. The Bariatric center here said that they are very hard to work with since the district is self insured and they don't want to pay out for the surgery. We were told that one of the Nurse's were told (by an insurance rep at the district) that they were going to make it almost impossible or give the run around to make the people give up and not want the surgery anymore! That just made me want to beat them even more! I will not give up nor will my Husband! I will update later as more comes along. I am at the waiting for approval after the first letter stage and my Husband is on hold due to some records missing from his file.
3/4/05
WE ARE APPROVED!I have been calling the case manager about 2-3 times a week so see how the status is.
Before I started doing this they were dragging their feet not giving me any responses just that it was being reviewed. Now I knew they did not want to approve, so I called and asked her how I could make her job easier and if there was anything missing I would take care of it and get back to her. Well I provided extra documentation and told her my appointment dates with the primary Dr. so that they were aware that I was going to continue to see the Dr. and not give up.
I guess they approved us so that I could stop calling. My Husband said that if he were handling it that we still would be on hold! How true if you truly want something you must show interest in it and go after it. I just had to ask myself HOW BAD DO I WANT IT? I really want this badly so I went after it and showed that I was going to bug until I got an approval or denial. I think most people are afraid to call the insurance people. You know we pay them and therefore have a right to ask on our accounts! Thank you all for your support.
|
| Source |
Margie's L |
| Insurer Policy |
Access Medical (hmo) |
| Insurer Status | Approved after first letter (07/04/04) |
| Weeks to approval |
2 |
| Comorbidities |
mild sleep apnea |
| Policy |
Don't know |
| Comments |
The nurses at the bariatric center worked so quickly on my case and got my insurance to approve me two months before my surgery. It was done when I wanted it. Everything was done so fast that I will always be greatful to all. If you have access insurance you are sure to be approved immediately. It has been the greatest experience in my life. |
| Source |
Sylvia H |
| Insurer Policy |
Access Medical (PPO) |
| Insurer Status | Approved after appeal letter (4-28-05) |
| Surgery Type |
Laparoscopic RNY - proximal |
| Weeks to approval |
2 |
| Pre-Op BMI |
53.6 |
| Comorbidities |
HBP, venous insufficiency, perpheral edema, need hip replacement |
| Policy |
Must be medically necessary |
| Comments |
Dealing with my insurance company was fair. They request that this is a last resort, also there must be a 6 month supervised diet. I was denied at first as all of the documentation was not ready when submitted the first time. I sent in an appeal letter on April 18th and and as of today (April 28, 2005) I was approved.
My recommendation to any one with Access, get a copy of the guidelines and follow the 6 month diet. Have good documentation. I used a registered dietation and with the help of my doctors letters it was approved.
Now I am just waiting for the hard copy of the letter so the Bariatric Center can set up appointment with the doctor.
I received my letter of approval and all is set up for my surgery. I want to thank all of my doctors who helped me with the approval process. |
| Source |
Mimi M |
| Insurer Policy |
Access Medical |
| Insurer Status | Approved after first letter (01/17/05) |
| Surgery Type |
Open RNY |
| Source |
Gracie P |
| Insurer Policy |
Access Medical (ppo) |
| Insurer Status | Approved after first letter (02/06/05) |
| Surgery Type |
Open Fobi Pouch Gastric Bypass |
| Pre-Op BMI |
48.9 |
| Policy |
Don't know |
| Source |
Wendy V |
| access plus and medicare |
|---|
| Insurer Policy |
access plus and medicare |
| Insurer Status | Approved after first letter (10/15/06) |
| Surgery Type |
Laparoscopic RNY |
| Comorbidities |
Depression, Diabetes, GERD, Hypercholesterolemia, Hypertension, NASH syndrome, bilateral carpal tunn |
| Policy |
Don't know |
| Source |
Rosalinda B |
| Accordia |
|---|
| Insurer Policy |
Accordia (EPO) |
| Insurer Status | Approved after first letter (12/15/06) |
| Surgery Type |
Laparoscopic RNY - proximal |
| Weeks to approval |
2 |
| Comorbidities |
Hypertension |
| Policy |
Must be medically necessary |
| Comments |
Process was surprisingly quick and easy. I was prepared for the battle of my life, but they didn't even request any medical documentation. |
| Source |
M B |
| Accountable Health |
|---|
| Insurer Policy |
Accountable Health (PPO plus) |
| Insurer Status | Approved after first letter (08/17/01) |
| Surgery Type |
Open RNY - proximal |
| Weeks to approval |
5 |
| Pre-Op BMI |
48.7 |
| Comorbidities |
GERD, Back Pain, HTN |
| Policy |
Must be medically necessary |
| Comments |
They required proof of active dieting without success for the past 5 years. No exception would be made on that. They also would make no exception for "out of network" physicians. Once I found an "in network" surgeon and got them the medical records from my past dieting adventures, they faxed me a letter that day. So all in all, not bad to work with. I just think they miss the point that you don't want to scrape the bottom of the barrel to find your surgeon. I got lucky to find such a great organization to do my surgery! |
| Source |
Lisa B |
| Insurer Policy |
Accountable Health (PPO) |
| Insurer Status | Approved after first letter (12/2/06) |
| Surgery Type |
Laparoscopic RNY |
| Comorbidities |
Sleep apnea, GERD, Diabetes, Hypertension, Depression, Shortness of breath, Stress incontinence |
| Policy |
Must be medically necessary |
| Comments |
I was approved on the first try. Our benefits case worker has been wonderful. No problems, I would recommend this insurance to any body. Only thing holding some people back is that they require five (5) years of documented weight loss efforts. I unfortunately have that, but most people don't. |
| Source |
Dana A |
| Accountable/Interplan |
|---|
| Insurer Policy |
Accountable/Interplan (PPO) |
| Insurer Status | Approved after first letter (05/09/05) |
| Surgery Type |
Open RNY |
| Weeks to approval |
1 |
| Comorbidities |
Diabetes, Hypertension, Hypercholesterolemia |
| Policy |
Must be medically necessary |
| Source |
Terri H |
| Acordia |
|---|
| Insurer Policy |
Acordia (guadalupe gonzalez) |
| Insurer Status | Denied after first letter (12/30/00) |
| Source |
Amanda S |
| Insurer Policy |
Acordia (PPO) |
| Insurer Status | Denied after first letter (08/10/05) |
| Source |
Kathy L |
| ActiveCare2 |
|---|
| Insurer Policy |
ActiveCare2 |
| Insurer Status | Approved after appeal letter (09/22/04) |
| MD-supervised programs |
4 (147 weeks) |
| Source |
Jill F |
| Admar |
|---|
| Insurer Policy |
Admar (Central Benefits) |
| Insurer Status | Approved after first letter (08/09/01) |
| Surgery Type |
Open RNY |
| Pre-Op BMI |
40.4 |
| MD-supervised programs |
1 (4 weeks) |
| Source |
Ronnie C |
| aenta |
|---|
| Insurer Policy |
aenta |
| Insurer Status | Approved after first letter (10/14/05) |
| Surgery Type |
Open RNY |
| Pre-Op BMI |
44.4 |
| Policy |
Don't know |
| Source |
Karyn I |
| Insurer Policy |
Aenta |
| Insurer Status | Approved after first letter |
| Weeks to approval |
2 |
| Policy |
Must be medically necessary |
| Source |
Monica R |
| Aetma |
|---|
| Insurer Policy |
Aetma |
| Insurer Status | |
| Surgery Type |
Open Revision |
| Source |
Donna D |
| Aetna |
|---|
| Insurer Policy |
Aetna (Feds) |
| Insurer Status | Approved after first letter (08/16/00) |
| Surgery Type |
Laparoscopic RNY |
| Pre-Op BMI |
43.2 |
| Source |
Regina W |
| Insurer Policy |
Aetna (HMO) |
| Insurer Status | Approved after first letter (5/14/99) |
| Surgery Type |
Open VBG |
| Weeks to approval |
3 |
| Pre-Op BMI |
41.6 |
| Comorbidities |
Muscle Disorder, Sleep Apnea, PLMS, Fibromyalgia |
| Policy |
Must be medically necessary |
| Source |
Colleen H |
| Insurer Policy |
Aetna |
| Insurer Status | Approved after first letter (5/01) |
| Surgery Type |
Open RNY |
| Pre-Op BMI |
54.9 |
| Policy |
Don't know |
| Comments |
I had no problems at all with Aenta HMO. Was approved within 1 week. I didn't have to contact them at all...was all done through the doctor's office. |
| Source |
Diane N |
| Insurer Policy |
Aetna (Open Choice PPO through Micros) |
| Insurer Status | Approved after 2nd appeal letter (10/3/00) |
| Surgery Type |
Open RNY - proximal |
| Weeks to approval |
90 |
| Pre-Op BMI |
51.5 |
| MD-supervised programs |
3 (30 weeks) |
| Comorbidities |
Hypertension, Diabetes, Major Depression, Herniated Disc L4-5, probable sleep apnea |
| Policy |
Must be medically necessary |
| Comments |
Microsoft had a written exclusion policy against ALL obesity treatments. Two appeals through benefits failed in 1999, but they just changed their policy as of 1/1/00. Surgery is now covered when medically necessary. Two appeals in 2000 have resulted in approval and a date!! (11/16/00)
They needed medical records to document repeated failures with doctor- supervised diets. |
| Source |
Laura S |
| Insurer Policy |
Aetna (chevron phillips chemical co) |
| Insurer Status | Denied after first letter (05/26/01) |
| MD-supervised programs |
1 0 |
| Comorbidities |
i working on finding out |
| Policy |
Don't know |
| Comments |
Q1 don't know how to talk to , i get the run-around.
Q2 took the over a month to deny it.
Q3 As long as they can
Q4 ??Don't know yet just starting to fight!
Q5 NEVER SURRENDER, WIN IT ALL, KEEP AT THEM
|
| Source |
Kevin V |
| Insurer Policy |
Aetna (US Healthcare) |
| Insurer Status | Approved after first letter (01-16-01) |
| Surgery Type |
Open RNY - proximal |
| Weeks to approval |
3 |
| Pre-Op BMI |
54.9 |
| Comorbidities |
diabetes, fam hx of heart attack |
| Policy |
Must be medically necessary |
| Comments |
I never had to deal with Aetna because Neweigh does it all. :-) I've heard that most people get their approvals in about 2-3 weeks so I don't think they stall at all. From what I know and have heard, aetna is one of the best at giving approvals. I'm happy with them. |
| Source |
Dana H |
| Insurer Policy |
Aetna (ppo) |
| Insurer Status | Approved after appeal letter (01/27/00) |
| Surgery Type |
Open RNY - distal |
| Weeks to approval |
6 |
| Pre-Op BMI |
51.7 |
| Comorbidities |
sleep apnea, arthritis, hypertension, diabetes |
| Policy |
Must be medically necessary |
| Comments |
You must be persistent and make sure your SURGEON writes the letter requesting approval. Be sure and provide records of weight loss attempts and medical problems caused by the obesity. I think they all deny for any reason, not just obesity the first time to stall. Yes I think they respond to persistence.
Keep good records and copies of what you send. they seem to lose it everytime.
They are professional so be professional. I owe the insurance companies a lot and am ever so grateful for their approval and for their paying most of my expenses. From their point of view, they ARE paying out a lot of money and we just need to continue to educate them on how successful this surgery is and how many health problems it will prevent and save them money later.
|
| Source |
Cathy H |
| Insurer Policy |
Aetna (HMO) |
| Insurer Status | Approved after appeal letter (04/08/02) |
| Surgery Type |
Open RNY - proximal |
| Weeks to approval |
2 |
| Pre-Op BMI |
49.9 |
| MD-supervised programs |
3 (58 weeks) |
| Comorbidities |
sleep apnea, painful joints, GERD, clinical depression, anxiety |
| Policy |
Must be medically necessary |
| Comments |
10/18/99 Great West (One Health Plan) requires 1) Certificate of Medical Necessity 2) Psychiatric Evaluation 3) Documented previous weight loss attempts. All this information was sent to the medical review nurse today and I was told it was being forwarded to the physician review board and should take about 2 days for a decision.
10/20/99 When I called to get the status from the insurance I was told it was denied. I left a message for the manager of the review board to fax me the denial letter because I was going to appeal it through Walther Linstrom. 20 minutes later the manager called me back and said it was denied because I did not have 12 months of *continuous* medically supervised diets. I explained that the lapse in the last two programs I was on was due to the 2 knee surgeries I had in between. The manager said that was a good enough reason for him and over-rode the denial right there on the phone!!!! I was shocked and excited!!! |
| Source |
Julie M |
| Insurer Policy |
Aetna |
| Insurer Status | Approved after first letter (09/24/99) |
| Weeks to approval |
3 |
| Policy |
Must be medically necessary |
| Comments |
I switched insurance providers the first
of the year. Once I got all
the ducks in a row (had insurance card
in hand, appointments, etc.) it took
about three weeks for processing of my
request.
They did require a letter from current
PCP saying I had tried other means in the
recent past to lose weight. Before they
were taken over by Aetna, this was not
necessary. In fact, they would do approvals
on phone call from surgeons.
This is an enlightened insurance company.
My insurance is through civil service employment.
|
| Source |
L. E. S |
| Insurer Policy |
Aetna (POS) |
| Insurer Status | Approved after first letter (11/04/99) |
| Surgery Type |
Open RNY |
| Weeks to approval |
5 |
| Pre-Op BMI |
45.3 |
| MD-supervised programs |
3 (15 weeks) |
| Comorbidities |
Sleep apnea, diabetes in family, hip pain, knee pain, heart pain/problems |
| Policy |
Must be medically necessary |
| Comments |
Well, approved after 1 month and 2 days. Also,
had to provide diet history, but, wasn't a big deal.
Tracking down the records wasn't fun, but, paid off. |
| Source |
Jen L |
| Insurer Policy |
Aetna (hmo) |
| Insurer Status | Approved after first letter (06/12/01) |
| Surgery Type |
Open RNY |
| Weeks to approval |
5 |
| Pre-Op BMI |
52.5 |
| MD-supervised programs |
1 0 |
| Policy |
Must be medically necessary |
| Source |
Melissa J |
| Insurer Policy |
Aetna (railroad) |
| Insurer Status | Approved after appeal letter (10/05/99) |
| Surgery Type |
Open VBG |
| Weeks to approval |
7 |
| Pre-Op BMI |
51.1 |
| Comments |
great company, Only asked for proof of Dr. assisted diet, then approved right away.
They were always very nice, even when I was calling SEVERAL times a day. |
| Source |
Terri G |
| Insurer Policy |
Aetna (PPO) |
| Insurer Status | Approved after first letter (10/04/99) |
| Weeks to approval |
3 |
| Policy |
Must be medically necessary |
| Comments |
Aetna approved me in 3 weeks. I knew I was going to have problems because I was the leaving the company that I worked for, and I knew that I would need to go on COBRA.
My doctor's office submitted my paperwork to Aetna on 9/25/99, but my insurance lapsed. I waited for the COBRA paperwork to come, I signed up, and overnighted my premiums (that was 11/1/99). The case nurse at Aetna actually received the paperwork on 11/5/99 and we got approval today!! I know they had nothing to do with everything that happened from the time my doctor submitted the paperwork to the time I sent in my premiums.
Getting my approval was worth the wait!!
In dealing with Aetna, be persistent!! It really pays off. |
| Source |
L. V |
| Insurer Policy |
Aetna (PPO) |
| Insurer Status | Approved after first letter (10/20/99) |
| Surgery Type |
Open RNY |
| MD-supervised programs |
1 (10 weeks) |
| Comorbidities |
GERD, Sleep Apnea, arthritis |
| Policy |
Must be medically necessary |
| Source |
Katherine K |
| Insurer Policy |
Aetna |
| Insurer Status | Approved after first letter (10/17/99) |
| Weeks to approval |
2 |
| Policy |
Must be medically necessary |
| Comments |
DIDN'T HAVE A PROBLEM AT ALL |
| Source |
Michelle R |
| Insurer Policy |
Aetna (HMO) |
| Insurer Status | Approved after first letter (1/28/00) |
| Surgery Type |
Laparoscopic RNY |
| Pre-Op BMI |
45.7 |
| MD-supervised programs |
2 (28 weeks) |
| Comorbidities |
sleep apnea, high blood pressure, screwed up menstrual cycles, sexual dysfunction and urine incontin |
| Policy |
Must be medically necessary |
| Comments |
My surgeon is just now in the process of submitting my info for approval. I will update with more info once I hear back from the dr. on my approval.
I am on Aetna HMO and was approved in 48 hrs. My file was sent to the medical director and she approved this really quick.
My surgery will be covered 100%. |
| Source |
Kim H |
