Hello all. I began this jounrney to my weight loss surgery in March of 2010. I visited Dr. Custer in Ohio and he felt I would be a good canidate for the Lap band. I have aetna insurance with Buckeye as a secondary. (I just got Buckeye within the last month). So, with aetna you can do the 12 week nutritional class or the 6 month with your pcp. I did the 12 week class at the barix clinic and also met with my pcp once every 3 months. My pcp was very supportive-filled out in detail what I did during those 3 months on my file. There was other ciriteria to meet of course and I did.

I am 31 years old and weigh 285. Been dealing with obesity for my whole life. The lady that I am working with from Dr. Custers office thru all this said I did everything 110% correct. My file was submitted to aetna on June 22nd 2010. July 3rd I got word that it was denied and would go to appeal. I was told that the medical reviewer denies 9 out of 10 cases that get to his desk..so it went to appeals which means that in July it went to my employer which is the East OHio Conference. I wrote a letter to go with my file at that time telling more about myself and all the options i have did before to try and lose weight....a 2 page letter that I wanted to go with my file so that I wasnt' just a number. Well, I head back from the lady at Dr. Custers office yesterday morning and she said it was denied again. She feels that the East Ohio Conference are just siding with Aetna becasue they don't know how/or what to do to handle this. I got on the phone after that call and called and spoke to the lady at the East Ohio Conference that handled my file and asked her for more info. What she told me is that she feels I should try optifast again....she feels that there are other ways I can lose weight..she feels that I should do another  month diet...I got all these answers from her and it was like her opinion!! She kept referring to an insurance program that the east Ohio Conference used to have that was more strict on guidlines for weight loss surgery..I feel like I have hit a very hard wall.

I KNOW I have met all the crriteria to get the weight loss surgery. I did everything 110%. If I appeal this again..it will just go back to the East Ohio Conference. And I was told within time the 12 week nutritional class does expire. So I will have all that plus more dr. offices out of pocket to meet my deductable yet again.

What do I do? I feel sick at the thought that this means I am back to the drawing board.

Any advice out there? I need it terribly.

Thank you,
Angie

This one is hard, an appeal could go either way. Have you tried a peer to peer review?

Yes, 30 is obese but most ins co's don't pay until you are morbidly obese.

I agree with Maria. Just because you'll have ins that does not mean they will cover bariatrics.

If it does cover bariatrics each plan is different on their requirements.

They are not permitted to do this. Your starting BMI is what matters. This one should be an easy peasy appeal.

Why were you originally denied?