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I'm curious if you ever got your question answered and if so what were the steps you were given in order for aetna to pay for it. I'm also switching from BCBS to Aetna POS ii. Any advice would be helpful. Thanks!
I have begun the process of seeking gastric bypass surgery and will be meeting with my surgeon (Dr. Francis Teng) on Tuesday. At the seminar, he said that Amerigroup (Medicaid) is awful to deal with and put out many roadblocks to getting the surgery. That 4-5 months ago the wait was 3 years of supervised weightloss and now its 6 months but may change again in January. He then suggested that I buy a private insurance to make the process easier. Anybody else have experience with getting approved by Amerigroup?
BCBS has denied my request for conversion surgery. It seems they look at it as two surgeries: band removal, which they won't approve because I don't have any catastrophic problems with it; and WLS, which they won't approve because my BMI is too low!
I was banded in 2007 and lost 100 pounds. I was very successful at keeping it all off for about 5 years. Then slowly over about a 1.5 to 2 year period I gained back about 30. I have always had bad reflux, sliming, PBing, etc. You all know the story. Now my doc tells me that my esophagus is stretched and she emptied my band. Of course I gained another almost 30 pounds in about 3 months. She's been telling me for a couple of years that I should convert to the sleeve and I finally agreed. After jumping thru all the hoops required by the insurance company, they denied me.
Has anybody successfully appealed a BCBS decision?
"Ones character can easily be judged by how you treat people who cannot help you".
Medicaid covers the surgery. I was told this by a social worker at my local health department who looked it up on Medicaid's website. This is where I go to see my primary care physician. I pay a $3 co-pay there and everywhere I go for Medicaid covered services. If it were me, I'd try to get myself established with a primary care physician who accepts Medicaid as soon as I could. Medicaid will need 5 year's worth of medical records showing where you've struggled to lose weight through other methods like Weigh****chers or calorie counting, etc. You'll also have to go on a 6 month physician supervised diet before Medicaid will approve you for surgery. And your primary will have to write a letter of medical necessity to Medicaid. Different hospitals require different things. Most require you to attend an educational seminar where they will explain the surgeries and try to answer your questions. I don't know anything about Duke specifically, but if you go to their website for their surgical weight loss program, you can probably find a phone number to call for more information.
I hope this helps! Let me know if you have other questions and I'll try to help you.
Hello, Lady!!
I am glad someone reached out. I feel like I am in uncharted waters. However, I do have a question or two for you.
How do I even get in a see a Primary? Do I have to chose that ahead of time?
What about Duke? I should have done this years ago, but I was TOO scared and now I am regretting it as life takes you where it wants you to go. :)
I look forward to sharing info with you, but I sorta had given up, but I now have renewed spirit.
Please let me know what you find out and I will do the same.
A
Hi,
I have NC Medicaid too. I talked to my PCP last night. Medicaid covers the surgery, but you are responsible for paying for the pre-op appointments such as tests and the psych evaluation. However, if you go to a practitioner that accepts Medicaid, then I'm assuming you'd pay whatever your normal co-pay is. I'm not 100% sure of this. I'm trying to find answers too. When I find out, I'll let you know. I am trying to decide between 2 hospitals--Wake Forest University Baptist Medical Center in Winston-Salem or Catawba Valley Medical Center in Hickory which is closer for me. For Medicaid patients wanting to have the surgery at Baptist, I was told there was some kind of an 18-month waiting list just to get into the program, which is another reason I'm considering the hospital in Hickory.
Good luck to you, and like I said I'll let you know what I find out.
I just wanted to give some hope to IEHP ladies and gentlemen since they can be a pain! I finally got a consultation september 10 2015 my authorization was sent MONDAY November 16, I received approval this morning November 18!! Scheduled for RNY January 5th 2016!
Sorry to have taken so long to reply!
I did get my approval. I followed every guideline to the letter and while it took them until the 11th hour (the day before surgery) to approve, I was in fact approved.
Aetna's hesitation came from a mix-up in the submission; my doctor's office had submitted with some incorrect dates and it looked like I hadn't done my full 4 months of pre-work. When this was corrected, my doctor submitted an appeal to expedite approval so I could keep my surgery date.
Did you find out why you were denied? Do you seem to meet all the criteria (BMI, medically supervised diet, etc.)?
Keep up the fight. If WLS is the right decision for you, don't give up. It has completely changed my life and I hope you'll find a way to get there.
Best
Christine
________
137 pounds lost - from a 24/26W to a size 8/10!
Do you have a secondary insurance that pays the 20%that medicare doesn't.?
Hockeymom87 · 0 replies · 809 views
