Recent Posts
Topic: RE: Aetna Appeal Letter
Hi,
I have also been denied by Aetna for bariatric surgery. I wrote an appeal letter two weeks ago explaining my co-morbidities and providing a copy of the doctor's letters diagnosing me with diabetes, sleep apnea and stress incontinence. Aetna is refusing to recognize the co-morbidities and stating that my BMI has not been at 40 for the past two years. I am arguing that my BMI has been at 35 with the co-morbidities for the past two years. So, my question is, what type of information should I provide to show that I suffer from the co-morbid conditions. I provided them with my doctor's letter for the diabetes, along with the contemporaneous medical records from the doctor's showing that I was being treated for diabetes and that I was currently being prescribed metaformin. Any insight you can provide will be appreciated. I am really distraught because I thought for sure that the surgery would be approved this time. Thanks, Gail
I have also been denied by Aetna for bariatric surgery. I wrote an appeal letter two weeks ago explaining my co-morbidities and providing a copy of the doctor's letters diagnosing me with diabetes, sleep apnea and stress incontinence. Aetna is refusing to recognize the co-morbidities and stating that my BMI has not been at 40 for the past two years. I am arguing that my BMI has been at 35 with the co-morbidities for the past two years. So, my question is, what type of information should I provide to show that I suffer from the co-morbid conditions. I provided them with my doctor's letter for the diabetes, along with the contemporaneous medical records from the doctor's showing that I was being treated for diabetes and that I was currently being prescribed metaformin. Any insight you can provide will be appreciated. I am really distraught because I thought for sure that the surgery would be approved this time. Thanks, Gail
Topic: RE: BCBS/IL PPO Denial #2 !!!
Yes, finally. I had surgery 05/18/09. I'm now 100 lbs down and living life to the fullest. I really need to update my personal blog on here. You should go there and read all my old blogs. I was pretty good in the beginning to cover my journey. The further out you get the more "regular" life becomes and a lot of us seem to drift away from obesity help a bit.
As far as the insurance fight, it was a hard battle to be sure. Both before and after surgery but you have to hang in there. Appeal your denial with all the reasons why you DO qualify. Just be prepared emotionally, I had to do it twice. I re-read and took from their website the section on qualifying for weight loss surgery - like when they said I hadn't been compliant with my doctor supervised diet, I pointed out I had followed and completed his program exactly. A specific amount of weight loss was not a criteria stated in those insurance qualifications so that denial didn't hold up because they didn't list it. I met all the other qualifying reasons for WLS: I had multiple co-morbidities (diabetes, high blood pressure, hyper lipedemia). Construct your letter in such a manner that you cover all your health issues point by point, including how your current state of obesity negatively affects the quality of your daily life. I wore slip on style shoes because I couldn't bend over to tie them because of my large stomach. I couldn't walk a flight of stairs without losing my breath and heart pounding. Describe in detail exactly how you feel every day. You have to convince them. No one can do this better than yourself. Don't feel like you're being gross or too personal either. They need to know graphically - these are doctors that review these records anyway, they've heard/seen it all before so don't be afraid to list personal details that make daily life unbearable for you. List all the diets you have tried (and failed at) too. Ask your surgeon if he will give you a supporting letter of surgical need. Attach copies of any previous diet plan records if you have them, doctor's records that show the diagnosis codes for any co-morbidities, recorded weight, etc. My second denial was for not having proof of a 5-yr weight history showing morbid obesity. Thank goodness I had an emergency room visit and was able to get a copy of those records that proved to them I had been "fat" long enough. It's just ridiculous what some insurance companies will put you through. Again, hang in there. Write that appeal letter and mail it off and then be patient. I know that's hard too - the waiting. Total time for me from when my doctor submitted my stuff to insurance to the time I was finally approved was 3 months. It was pure agony for me. If I can help you in any way, let me know. I would be glad to pay it forward. I had help with mine from another obesityhelp member. This is a truly great website for anyone on a weight loss journey.
Hugz - Pat
As far as the insurance fight, it was a hard battle to be sure. Both before and after surgery but you have to hang in there. Appeal your denial with all the reasons why you DO qualify. Just be prepared emotionally, I had to do it twice. I re-read and took from their website the section on qualifying for weight loss surgery - like when they said I hadn't been compliant with my doctor supervised diet, I pointed out I had followed and completed his program exactly. A specific amount of weight loss was not a criteria stated in those insurance qualifications so that denial didn't hold up because they didn't list it. I met all the other qualifying reasons for WLS: I had multiple co-morbidities (diabetes, high blood pressure, hyper lipedemia). Construct your letter in such a manner that you cover all your health issues point by point, including how your current state of obesity negatively affects the quality of your daily life. I wore slip on style shoes because I couldn't bend over to tie them because of my large stomach. I couldn't walk a flight of stairs without losing my breath and heart pounding. Describe in detail exactly how you feel every day. You have to convince them. No one can do this better than yourself. Don't feel like you're being gross or too personal either. They need to know graphically - these are doctors that review these records anyway, they've heard/seen it all before so don't be afraid to list personal details that make daily life unbearable for you. List all the diets you have tried (and failed at) too. Ask your surgeon if he will give you a supporting letter of surgical need. Attach copies of any previous diet plan records if you have them, doctor's records that show the diagnosis codes for any co-morbidities, recorded weight, etc. My second denial was for not having proof of a 5-yr weight history showing morbid obesity. Thank goodness I had an emergency room visit and was able to get a copy of those records that proved to them I had been "fat" long enough. It's just ridiculous what some insurance companies will put you through. Again, hang in there. Write that appeal letter and mail it off and then be patient. I know that's hard too - the waiting. Total time for me from when my doctor submitted my stuff to insurance to the time I was finally approved was 3 months. It was pure agony for me. If I can help you in any way, let me know. I would be glad to pay it forward. I had help with mine from another obesityhelp member. This is a truly great website for anyone on a weight loss journey.
Hugz - Pat
Topic: RE: BCBS/IL PPO Denial #2 !!!
Did you ever get an approval? I am fighting BCBS/IL right now as well.
Topic: RE: "Exclusion" -- is there any hope?
Welcome, you'll find a lot of support on this site. I can't actually give you an answer to your dilemma, but i can advise you to post your question on the forum of the surgery you want to have. Those people have already gone through what you are going through now, and I'm sure that someone can help you.
Topic: i need help
ok mi mother its aperson shes obese person she need the surgery like in emergency, they toll me i need to get a insurance odf blueshield brule croos of illinois the have somany plans i dont know witchone to go with she need to get her surgery done please ppl help me i need to get all papper work done this week she is getting everyday worse im so scare to loose my mother
Topic: "Exclusion" -- is there any hope?
Hi, I have to first say that I am so happy to have discovered this site! My wife and I have both been obese since childhood, and we are both considering surgery. I am 32 years old, BMI = 47, known comorbidies include significant sleep apnea, shortness of breath, joint pain, and severe GERD that was corrected in '09 by hiatal hernia surgery. It is clear that my obesity is affecting my health.
However, I have United Health Care Choice Plus, and "Surgical and non-surgical treatment of obesity" is bluntly listed in the exclusion section of my pollicy. I called the customer service line and was told bariatric surgery was excluded an there was nothing I could do. Does this mean a definite "no, don't even bother," or is this where letters from doctors, etc. can help?
Thanks a lot!
Mark
However, I have United Health Care Choice Plus, and "Surgical and non-surgical treatment of obesity" is bluntly listed in the exclusion section of my pollicy. I called the customer service line and was told bariatric surgery was excluded an there was nothing I could do. Does this mean a definite "no, don't even bother," or is this where letters from doctors, etc. can help?
Thanks a lot!
Mark
Topic: RE: So Frustrated with Tricare Prime
Have you been to Portsmouth yet? Because they told me it was a 4-8 month process. also, another poster had her hers done in a 2 month time window after her initial orientation.
Topic: RE: losing weight during presurgery diet - disqualification?
I am in my third month of the six month supervised diet with a doctor. I have not requested approval yet becuase I knew without it completed I would be denied. I am worrried because I keep gaining weight, I went on Adkins diet last year and restricted my carbs and sugars to less then 1 carb a day, I was desperate. After 9 months I lost 55 pounds, the thinnest I had been in over a decade, excpet when I was pregnant. I went off the diet becuase it stopped working, and I have gained 90 pounds in 8 months, I have been on the 3 month diet and have gained every month in the weigh in, I am going to the school fitness center with a personal trainer multiple times a week and doing cardio, and am now on phentrimine, with the dosage increased on month two. Will they disqualify me if I do not lose the 5%? It says in my policy that I am supposed to lose 5% from baseline as a result of the physician supervised diet, and I cant make my body do it. I come from a family of severly obese people, 400,500, 800lbs in some cases. I do not know if there is something in my genes, or if I ruined my metabolism further, but I am really worried.
Topic: Has this happened to anyone?
I had the gastic lap band in 2004 and have lost about 100 pounds. I recently saw a plastic surgeon for a tummy tuck. The office submitted the procedure information and it was approved on 2/23 then I received a disapproval notice on 3/03 with no reference to the initial approval. The doctor's office and the insurance company (Anthem Blue Cross Blue Sheild) are checking to see what happened. I've been pretty down since the notice but staying hopeful.