I appreciate everyone's input.

I have found myself wondering why I have been denied 2 times. When I was denied by Aetna the first time, the lady that I have been working with at the surgeons office told me that the medical reviewer from Aetna that denied my case denies practically everyone. As soon as they seen which reviewer I had they knew it wasn't good news. Well, with how this plan is set up-once it goes to Appeal- it goes back to the Employer-which was East Ohio Conference.

Once the surgeons office called me this week and said that it was denied again, I called there. Spoke with the lady who had my file. She was half rude and I could tell she didn't have a clue what the requirements were herself. Here is a what her letter that I got yesterday said.

Dear Mrs. Garrabrant.

This letter is in response to your appeal dated August 4, 2010. regarding the denial by Aetna for a laparoscopic gastric banding procedure. At this time, we must concur with Aetna's determination.

Angela, I'm not certain if you are aware of anothe rweight loss provision under the Conference Health Benefit Plan that may be helpful for you at this time. For more info, please call. xxx-xxx-xxxx.

Sincerely...
xxxxxxxxxxxx


That was all I got. No reason why. Even when I called her she told me that she felt that I should do another 6 month diet-or wait until March so I can begin again. She told me to try Optifast again. I asked her if she recieved a letter I had mailed to the office-kind of my story..etc. So that I wouldn't just be a number. She did get that letter and told me she has 2 daughters herself and she couldnt' approve something that could threaten my life (surgery for weight loss)..CAN SHE/THEY do this????????

My first denial with the medical reviewer from Aetna didnt' even give a reason-and he did a peer to peer with my PCP who supports me and this surgery 110%.

I don't want to settle with this. I feel I have been treated wrongly. I am going to call the surgeons office on Monday and see what I can do next..I don't even know how many appeals I have left but I know that if I appeal again it will go right to the East Ohio Conference.

Who else can I get involved? I feel as if I am in sinking sand!!

Angie

I am unsure of what to do. I have tried to get insurance before but because of my issues I have been denied. 

The last few surgeons I have spoken with would like me to get insurance before surgery as a back up. I am not sure what to do since I have been denied in the past. 

I'm 99.9% sure that's not correct.  And honestly, it should be that way.  If they made a law saying they HAD to insure you no matter what, no one would get health insurance until they got sick.

What is their reason for denial?  They should have provided you with a reason of why you were denied such as lack of 2 year history of obesity, BMI did not meet requirements, etc...  What was their reason?

 Oh I am SO sorry to hear this.  I'm really furious with the way this whole system works!  You have to work your ass off, pay the co-pays, attend a million meetings and appts NOT KNOWING if you'll be "approved" for surgery?!  It's nuts.  Your insurer should approve you if a doc says it's necessary.  Short of they you should be able to get a "conditional approval" based on completing your doc's requirements.  This really gets me steamed.

What are their reasons?

All I can do is hope for you and hope that your doc is very good at this.  Is there a dedicated insurance person at the office who handles everything?

Hearts and more hearts ...