AETNA INSURANCE HELP

I have an Aetna HMO with an Exclusion for WLS.   I had an RNY done in 2000 under another insurance and infortunately I have gained most of my weight back.  Before my surgery I had diabetes one of my co-morbilities and am headed back in that direction with my weight gain.  I want to have a revision and unless there is something wrong with my previous surgery my insurance wont pay to have this done.  I was told there is a statute of some sort that states if you have diabetes that no insurance company can deny you surgery.  I need to get the information on this so I can fight with my insurance company.  Can anyone tell me how I can get this information??  PLEEEEZ any information would be a big help!!

I have never heard anything like that. What source did you use. I would ask them for more info. Unfortunately, my understanding that excluded means just that and few can make an insurance company pay for something specifically excluded in the contract. I truly hope someone here has the answer for you. I pray that even if insurance won't pay that God blesses you with another way.

Thank you for your blessings!  I am NOT giving up on this.  I hope you are successful in getting your surgery soon!!

Yes I work for the County and the insurance is Self Funded.  I was doing further research and found out this information on the Aetna Web site.  www.aetna.com/cpb/medical/data/100_199/0157.html It states under Repeat Bariatric Surgery (page 4) that Aetna will pay for revision surgery IF there is an obstruction or stricture (which I don't think I have) OR it states if the procedure failed due to dilation of the gastric pouch it is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation and the member has been compiant with a prescribed nutrition and excerise program following the procedure.   Isn't dilation of the gastric pouch basically the pouch being enlarged (which is probably the issues in my case) ?  I am waiting to have an upper GI done to see if there are any issues in my case but was hoping when I read this from the Aetna site that  MY PRAYERS WERE ANSWERED!!! What are your thoughts on this? 

Paul how do I find out if my employer used the standard Aetna product as their written plan??  I do appreciate your help on this!

Well dilation is "act of dilating or stretching" so my thoughts would be that if the pouch has gotten larger and you have been following your exercise and follow your nutrition plan that the revision may be something that is needed. Sounds like you have a hope to run with. It may be an uphill run (ugh) but you can stand on top of the hill and enjoy the view when it is over. Keep us posted on your success!

Not to dash your hopes... just to forewarn you so you might have a response prepared, if necessary...  A coworker regained much of his weight after losing it via  RNY, and the insurance company denied a second surgery because they claimed that if his pouch was enlarged it was because he had eaten too much (and therefore NOT followed the appropriate nutrition plan).  he appealed, but to no avail (but I don;t know the details). Good luck.  I hate dealing with insurance plans. Lora