Question:
It seems my insurance Aetna PPO does not cover bariatric surgeries
I am so frustrated about all this, but I am not give up. As I said earlier, I finished all the running around since July, a date was set Oct 10 and pushed back to 17th, because they have not heard from the insurance company yet, I went on the 10 days high protein diet and then the 2 days liquid diet, on the 15th I called the surgeons office and was told that I was denied. Con you immagine that? I had some advice from Bama, the insurance guru, (by the way thanks BAMA) she advised me to call the insurance company and talk to them, which I did, they told me that they received my clinicals only on Oct. 14th and that they are still reviewing it, they will let me know the outcome of the review when they come to a decision. so you see, not only did the surgeon's office lied to me about the dates, but they are not so helpful, in anything, what I want to know now is can I change surgeon if I get approved? — sistalolo (posted on November 5, 2008)
November 5, 2008
I am so sorry that you are having such a hard time right now. How very
disappointing for you. To have gone through the pre-op diet and then to be
so let down. Again, I am so sorry. I don't have much advice for you as I
was a self pay, I just wanted to know that your post touched me. As far as
the surgeon goes, would you have to begin the process all over again if you
changed? I would certainly go to the office in person and ask to speak to
the office manager and the person that is supposed to be handling your case
and get to the bottom of it. Please hang in there and remember in the long
run, even though later than you'd hoped, you'll be on the loser's bench and
that is what this is all about.
Dawn Vickers
— DawnVic
November 5, 2008
HI...I have Aetna PPO as well and I was told, by Aetna, that the surgery is
100% covered as long as you are precertified. Is that what Aetna told you
when u called? I am concerned because like you to go thru all this and then
find out it is not is frustrating. I do also know that there are some
requirements like the 3 month nutritionist etc...well good luck...I will be
looking to see if u get approved!
— elimeno
November 5, 2008
Hi, I am not sure if this applies to all insurance companies, but I have
Capital One Bluecross and it does apply to them. I changed doctors five
days before my surgery (Dr. Marema) because the first surgeon (Dr. Steve
Webb) decided one day before I was scheduled to have RNY with him, that he
would only do a lapband on me. I live in Germany and had been working with
the first surgery for about 4 months when he told me to come to the USA,
that I was approved, and had a few tests to complete before the surgery. I
did...everything was in place, including me having pre-ops done and he
changed his mind. Anyway to make a long story short, I changed doctors and
am very glad I did because my doctor now is simply one of the best, but I
did have to be reauthorized by the insurance company. Dr. Marema's team
were so great and got my new approval in 5 days!
If I were you, I would call the insurance and ask their policy. Secondly
and maybe even more importantly (even if you have to wait a week or so
more), I would check out other doctors since you feel so uncomfortable with
your current surgeon and his office. I had those same feelings about Dr.
Steve Webb and his office staff and am so glad I DID not have to deal with
people who are unfriendly and unhelpful during such a stressful and
critical time as when I had my surgery.
— kathryn_ann
November 5, 2008
Hi Elevo :) Good luck to you and hang in there!
I also have Aetna PPO and I am 15 months post-op! So it can happen, just be
prepared for a battle. I began my precert in October 2006 with Aetna. I
decided on my doctor, had my family physician and my gynecologist write me
a recommendation which I also sent to the insurance company. (by the way,
keep copies of ANYTHING you send to them!) The first letter I received
from Aetna almost 6 weeks later was a denial. Aetna required a 3-6 month
diet evaluation and several tests including a mammogram. This was already
late December so I started the diet program in January and began getting
the tests they had listed. In March, the last month of my diet program, my
surgeon's office, resubmitted my request for precert with everything Aetna
had requested. I gave them a couple of weeks to process and then started
the phone calls. You can NOT imagine how many phone calls and how many
different departments and people I eventually had to talk to. One person
would tell me it was a new claim and would take 6 weeks to process; the
next day a new person would tell me something completely different.
Finally, about a week or so later, I talked to a very nice helpful woman.
Someone finally with some sense, told me that since it had been denied the
first time, that I needed to write an appeal letter stating that I wanted
them to review my precert. She told me in great detail how to do that and
even gave me her fax number so that she could personally see that it got
where it needed to be. I wrote it that day!
I wish that was where this story ended... I waited at least 10 days before
I called Aetna back to see where we were. Again, everyday was a different
story. But each one ended up saying about the same thing; if it's in
appeal, it could take up to 6 months before they have to reach a decision.
I was heartbroken. It was now June 07, and I was hardly any closer than
where I started. I was here, watching my grandmother die in the hospital
with heart disease and my mom suffering with diabetes and severe sleep
apnea. I knew I was just on the verge of this myself. And even though I
began to think it was hopeless, I kept calling. Everyday to every other
day I would call and check on the progess... persistant. FINALLY, July
24th, 285 days later, the surgeon's office called me. "Lisa, guess
what I have in my hand!?!" They had received the approval letter and
they already had me a date scheduled for surgery - August 7th!
By the way, Aetna also told me that they did not receive my appeal letter
for almost three weeks after the day I personally faxed it to them. It sat
in someone's IN box for weeks before anyone even looked at it. So
becareful in believing everything they say. I know the day I faxed it...
and the day they "say" they received it.
BUT overall, it is worth the wait and trouble, so hang in there and don't
get too stressed up over it. It WILL happen! and you will be a year post
op before you know it too!
BTW, I was 330lbs on 8/7/07 (s-day) and now a terrific 190lbs! I can't
believe the way I feel now. I still have a few lbs to go, but I can't
explain how much better I feel, the energy I have, and the new self image!
It's worth it girl, and I would go thru it all again! Hang in there, it'll
happen before you know it!
P.S. Don't just settle for a doctor. Do some (a lot) of research and
visit with them before you decide. After you are precertified, it only
takes a couple of days to change the doctor. This is a major life
decision, and you want the best and someone you feel comfortable about
putting your life in their hands. That's heartbreaking to have a surgery
date and then it be postponed indefinitely. The surgeon's office should
not set up a date until they have the precert. That's not fair to the
patient.
Good luck to you and God Bless!
— LoserLisa
November 5, 2008
Call your insurance company immediately about changing doctors because what
else will the doctor's staff lie about? Sounds like hard work to get
approved only to get a lie from the staff. When you call get a list of
bariatric surgeons then check them against obesityhelp list of surgeons for
reviews.
— Corina C
November 6, 2008
I am sorry you are feeling frustrated but it might not actually be the
doctor's office that lied to you. I have had my insurance tell me some
untruths about the submission and approval of physical therapy sessions (I
had ankle reconstruction surgery early this year, before the Lap Band).
Also, it might be that your surgeon was required to submit a hard paper
package and that they did provide a fax submission on the date they told
you.
The thing about WLS is that most insurance companies have very stringent
requirements not only for the surgery but the surgeon performing the
surgery and the clinical setting of it. If you change surgeons at this
point, there is a good chance it will delay your surgery since the new
surgeon and the surgery location will have to be approved.
Unless you are unhappy with the services your doctor is providing, I would
not recommend changing surgeons at this point but it is a call that only
you can make.
— [Deactivated Member]
November 6, 2008
I am almost 5 months post-op and have lost approx. 70 lbs. Just wanted to
add a comment. Lisa has given you excellent advise. Etna is known for the
long delay. Try to reframe your thinking as this is the preparation phase.
The BIG question is your doctor and the process. The program I went
through required 6 months of preparation including a psychological,
mamogram, gyn exams, colonoscopy and nutritional counseling during the 6
months, which is exactly what the insurance company (medical mutual)
wanted. The program also had a list of letters of support including family
friends and all physician, counselors, therapist, anyone that had
professional or personal history. The Program Staff put everything
together and sent it to the insurance company. I was on a time crunch
because I wanted to get it done before I had to pay new deductible in a
fiscal year for the insurance company. After the packet was submitted to
the insurance company it was approx. 3 weeks and surgery was scheduled. It
was the Doctor's reputation for detail and his staff's ability to cope with
my anxiety and their skill in negotiating with the insurance company.
If your doctor's office is not being honest with you or you believe you are
not being provided appropriate services and cooperation you may want to ask
research his/her practice and post-op care. Trusting your gut instinct.
It has gotten you this far. Read Lisa's comments and take heart. Be
consistent and persistent and make copies.
Peace and blessings on your journey.
Redpetal
— redpetal_14
November 7, 2008
Dear Elevo - What insurance company and the name of the plan you have
doesn't determine what coverage you have. Only the actual plan document
(which is a legal, binding contract) can tell you that. You can get it from
your employer if you have employer-based insurance or from your agent if
it's private insurance. You especially need to look at the section of the
policy on exclusions. That's where they list the things that they won't
cover. If bariatric or weight loss surgery is there, then it's not covered.
If it's not there or is listed specifically as being covered, you then need
to look for the insurer's clinical policy bulletin or clinical practice
guideline document on the subject of bariatric or weight loss surgery. That
will tell you what they require in order to provide the benefit to you. It
often involves a BMI of 40, or 35 with co-morbidities, a three to six month
physician supervised weight loss program, and then whatever other
administrative requirements they have. If you're persistent enough, you can
usually find these documents on your insurer's web site. If not, call them
and ask for a copy to be sent to you.
— rodghearing
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