ANY HELP? - I am lost

Matt, I was also told by a C. S. rep for MDIPA that I was covered for WLS, I was denied coverage even though I live in a state that supposely mandates coverage for WLS due to the fact that my employer  (VERIZON) is large enough to self-insure and have an exclusion for WLS written into their policies, wonder what politician they paid off. Due to several co-morbities I took a home equity loan to pay for what I believe is my life saving surgery, my RNY was done on 2-11-08 at St Agnes in Maryland at a cost of 23K for a self pay patient. Best of luck to you on your endevor.

Matt, I have Aetna, and was approved 3 years after I started checking into it.  Aetna will pay for the surgery, the problem is when your employer has that exclusion.  It took me til 2007 before they finally lifted the exclusion. However, it doesn't sound like they have an exclusion, they just have strict requirements.   quote:  "Treatment of weight loss when another underlying severe medical condition is not present; outpatient prescriptions are NOT covered even when there is an underlying medical condition." Sleep apnea does count as a secondary co-morbitidy.  I would definately check with your HR department.. and not just a regular rep.  I'd push until I found someone who knew exactly what the requirements were. Dale

Hang in there guy, like you have already been told, check with some one in your HR dept  at work or who ever over sees your ins. I actually had them to print the companies policy for me to read. Since I had surgery I have had post op testing denied and have had to call the ins co and tell them that the co I work for does cover WLS.  I have found that if you talk to 3 different people you get 3 different answers.  pan head

I agree with what a lot of people wrote above look at all avenues including mexico, self financing and appeal the heck out of Aetna's denial.   Also go through you HR reps.  There is something fishy there with the multiple answer.  When you appeal, be prepared with as much documentation as you can think of.  When I sought my companies pre-approval, I included my weight history for almost 20 years, the results of all major weight losss attempts with Atkins, WW, Nutrisystem.  I outlined the support system I had in place, why this would be successfull, and how much the insurance company was paying for weight related medications and what they could expect to pay in future if I did not lose weight.  I was approved in a week.  I seriously believe that it was not so much the letter, but the fact that I tried to signal that I would be an appealing pain in the rump if I had been denied.   FIGHT, FIGHT, FIGHT it.  Go through the appeal process.  if you end up self funding, submit the claims for re-imbursement and fight any denials there too!   Good luck.  I had my lap band 3 weeks ago and I already feel lighter and more energized.

I'd appeal...it can't hurt, but it's very diffiuclt to overturn an exclusion.  You might try Obesity Law on this site, they give a consult for free and for a bit of money they will do some of the work for you.  IN reality you can probably draft a similarly worded appeals letter by yourself if you do a bit of research.  is self pay an option?  Getting a new job with new benefits? working at starbucks f??? 2 DSers just got surgery by getting jobs at starbucks...waiting 3 months till their benefits kicked in and submitting a claim.  They are both new post ops......so that might be a thought?   3 months of starbucks hell for a 'free" WLS.  They cover all 3 major surgeries (lap, RNY, and DS)> Scott

Matt, I too was denied coverage by my insurance company and decided to go the self pay route. My surgery was 3/10/08 and cost about 23,000 here in Indiana. Unfortunately I am one of the lucky 1% who has had complications, the Doc missed a leak in the staple line and I developed an abssess along with a sever infection. I was readmitted thru the emergency room and spent another 6 days and now that I am home I am having to have antibotic IV's and nutrition administered every night. (no eating or drinking anything for 4 weeks) The total cost for this 1 month process is going to cost me another 50,000, yes we are trying to get the insurance company to pay but as it was a direct result of the VSG surgery they are not yet budging. I still believe this surgery is the best thing I did and am glad I did it and know when they finally pull the drains and PIC lines out and I can resume eating my 4 oz's, I will be OK Art J.

Who cares   MEN are trying to have intelligent conversation here.  Don't you have a floor to mop or a toilet to scrub?  Why don't you hop a fast boat back to Tuna Town 

I'm assuming no spritzing of that thumb, huh? Nice job guarding the gates, Baha.

So far there is some hope........we wont know for sure until Monday. I called Aetna and spoke to them again and then I spoke to a healthcare advocate at Aetna for Lowe's (my employer). She at first said no the do not cover it, but then looked and saw that YES they do. She then called someone at Aetna and her manager and they too said that it was covered. We were all on a conference call and they said to send in my appeal, but I questioned that since that can take 180 days it says. Then the healthcare advocate got a little testy with the service rep since it was their mistake. She got back on the phone and said that the only reason they denied it was because it was at a non-network hospital. OMG another excuse! They have had many different replies on this but the denial just said it was not covered. We then checked the hospital and it WAS in the network! The surgeon's office wrote "New Britain Hospital" and it is actually called "Center of CT Hospital at New Britain" So now Aetna and the Dr's office are suppose to talk on Monday and reschedule me if it all checks out. I'LL BELIEVE IT WHEN I SEE IT. I refuse to get excited until the IV is in my arm and he is about to cut.