Insurance won't cover DS, is there anything i can do?
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.
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.
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%
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.
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.
There is room on this earth for all of God's creatures..
next to the mashed potatoes
There is hope.
Janet in Leesburg