Insurance won't cover DS, is there anything i can do?

Schmatzi
on 11/22/11 7:49 am - TX
Hi,

I have a few questions and would be very thankful if someone knows how to deal with this.

OK, so my husbands insurance at work is Aetna and I am on his plan. The clinical bulletin on Aetna's website says that the DS as a surgery is an approved surgery. I called them before I started the entire process with my policy number and they told me it is covered.

I now have only 4 weeks left of my pre-op diet and now they are telling me it is not covered. They say that my husbands employer chose to only pay for the lap band or the gastric bypass but not for the DS. I am so furious right now.

Is there anything I can do? I don't want a gastric bypass. I want a DS and with a BMI of 50 and Diabetis this will be the best option for me.

Has anybody had this before? Is there any way around the employer limiting the choice of surgery?

I would be very greatful for any response since I don't know if there is even a chance of fighting this.

Thank you  
calendargirl
on 11/22/11 8:09 am - Land of Oz, KS
DS on 04/20/12
The only way you will know for sure is to request a copy of your husband's company's health insurance coverage statement.  You should also ask for a copy of the bariatric treatment policy the insurance company uses to determine medical necessity.  You have a right to know what you are paying for. 

Generally these documents can be accessed over the internet provided you have the information requested at login (usually an ID assigned by your husband's company and/or info from your health insurance card). 

I would also consider calling back and saying you spoke to "name" on "date" who told you it was covered, and now you would like to reconfirm or be emailed the documents that indicate to the contrary.

C-Girl

Starting Stats: Ht: 5' 0" HW: 242 ~ SW: 229.9 ~ CW: 117 ~ Goal: 124.9 ("normal" BMI)
% EWL @ 03 months: 36%             % EWL
 @ 09 months: 80%
% EWL @ 06 months: 63%             % EWL @ 12 months + 2 weeks: 100%

(deactivated member)
on 11/22/11 10:14 am
Revision on 10/14/10 with
Schmatzi
on 11/22/11 11:07 am - TX
Thank you both. That at least gives me some hope again. I am ready to fight for it if there is any chance.

(deactivated member)
on 11/22/11 11:36 pm - San Jose, CA
 I'm not positive, but I don't think your employer or insurance company has a right to limit your surgical choices - if they cover bariatric surgery, they have to cover ANY surgery that is standard-of-care that your surgeon says is the right one for you. Contact your HR dept to obtain a FULL copy of your coverage document to see what it says, including what your route of appeal is. 
Schmatzi
on 11/23/11 12:31 am - TX
Thank you Diana. The coverage details we had so far in the GE booklet stated that Obesity Surgery is covered 100% if performed in a center of excellence. Aetna has on the clinical bulletin that DS is not deemed experimental or anything and is covered if the plan covers it.

My husband called the plan administrator and they said that GE is limiting the obesity surgery to Lap band and gastric bypass. He found out that we have two appeals after denial and if those get denied as well, then we can take it up to GE itself.

He will get the FULL coverage document from GE and we will see what it says. But in case it does state that it only covers the Gastric Bypass and the lap band, should I submit for approval for the Gastric bypass first and once that is approved ask for a DS instead and appeal my way up? Or should i submit for the DS in the first place and appeal my way up? And do you think they are going to give in at some point if I provide enough information why the DS is a better option for me?

I am ready to fight my way to a DS, but would like to know if there is any chance of me winning this.
(deactivated member)
on 11/23/11 1:06 am - San Jose, CA
So, it sounds like your plan is SELF-FUNDED, rather than fully funded.  This can be good or bad.  Self-funded means GE pays medical costs itself, and only pays Aetna to administer their policies - in other words, they take advantage of Aetna's skills at running an insurance program, but GE pays the actual medical costs, and is on the hook for the risk - it is self-insured.

The bad news is that GE is wider latitude in setting their coverage policies than a state-regulated fully funded insurance plan.  The only recourse after exhausting appeals with a self-funded plan is to file a federal law suit under ERISA, and that is expensive - and the employer relies on the fact that almost NOBODY would file such a suit, because the value of the potential win is almost always far outstripped by the cost of prosecuting such a case.

The good news is that (1) you don't have a bariatric exclusion, which has been held valid by the courts; and (2) that you DO have recourse to arguing to GE's internal review committee that the DS is the proper surgery for you.  But what it also means is that Aetna is going to deny the DS, based on the specious limitation included in your policy written, apparently, by GE.

So here is how I would approach this.  I would structure my request for the DS in two parts, and ask that each part be addressed separately and in order.  I would ask them to FIRST consider whether you are qualified for bariatric surgery, irrespective of which surgery.  I would then ask them to consider, assuming the answer to the first question is yes, to approve the DS over either the lapband or gastric bypass, because of YOUR medical cir****tances.  And I would back that part of the request for preauthorization with a letter of medical necessity provided by a DS surgeon who you SELF-PAY for a consult and preparation of that LOMN.

You should get an approval for bariatric surgery, limited to Lapband or RNY, out of this from Aetna.  You will appeal to Aetna, probably twice, to exhaust your internal appeals - you have to do this, even though it is utterly pointless.  THEN you will have an opportunity to appeal to GE.  They will likely send your appeal out to an external medical reviewer of THEIR chosing, who will either deny or approve your request - but at least that is an "independent" review (sort of).  And then perhaps you will get one opportunity to argue to the GE internal committee itself.  And you would argue not only medical necessity, but also how the DS would be economically the better choice for GE going forward, because your medical costs will be reduced over time compared to costs with less effective surgeries.

As I said, the only option for an appeal if this doesn't work is to file a federal suit under ERISA.  Or to change jobs and get better insurance.
Schmatzi
on 11/23/11 1:25 am - TX
Thank you, Thank you and thank you Diana. This really helped me and I finally understand the process. I guess I should start preparing my paperwork and have everything in place already when the denial comes to get through the appeal process as quick as possible.
Valerie G.
on 11/23/11 3:42 am - Northwest Mountains, GA
 Just to let you know, I used to work for Siemens, and I found out from a colleague that they had banned people from getting the CrapBand, due to several employees that suffered bad complications with the band, even though Aetna (hmmm) had it covered in the policy.  Said colleague got the RNY instead (because his wife said so).  I digress....

Valerie
DS 2005

There is room on this earth for all of God's creatures..
next to the mashed potatoes

Janet P.
on 11/23/11 3:29 am
When I had my surgery I worked for a company that was self funded. When I first submitted the paperwork, I was immediated turned down. Went to my HR rep and she worked with me and worked the proper channels. We got the denial overturned and they paid for everything.

There is hope.

Janet in Leesburg
DS 2/25/03
Hazem Elariny
-175

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