shelleycakes

On 6/20/2018 at 9:05 PM, susunorm said:

...My deductible is 1500. In network annual co insurance is 3100 including deductible,..... So from what I understand. Once I reach 3100 of paying my cost. They cover the rest, as long as in network?

Yes, you are correct. Once you meet your coinsurance limit or out of pocket maximum of $3,100 Aetna will pay 100% for in network providers.

First, I assume you called Aetna to make sure bariatric surgery is covered on your plan. Then read Aetnas clinical policy for obesity surgery and make sure you meet all the criteria listed & that you have done the required Physician-supervised nutrition and exercise program or Multi-disciplinary surgical preparatory regimen. If you've done everything required then you should be approved without issue. Good luck!

On 4/6/2018 at 5:26 AM, Brttnyj89 said:

I wish that this happened. However it was denied.

Sorry to hear that. Try not to let that get you down. So what now, has your surgeon come up with a new action plan to work towards an approval?

Strained Soups saved me while on the liquid stage. Tastes much better than broth. Yogurt & applesauce too.

Per healthcare reform you get a set # of visits (check your plans benefit details) with a dietitian or nutritionist for obesity screening and counseling. If billed as such, then it is considered preventive care & covered 100% by your plan.

The issue is that you are at the mercy of your Dr office & their billing practices. It all depends on what codes they bill. You can't tell them how or what to bill but its worth an inquiry.

11 hours ago, Brttnyj89 said:

Got the dreaded phone call today, my pre determination was denied. I have BCBS of TX. When told the reason for the denial there were a lot of doctor notes missing. They needed notes explaining how my band has failed. My doctor is doing a peer to peer review tomorrow. I feel completely hopeless and helpless. Has anyone had success with this?

Don't worry. The Dr should be able to to clear it all up with the medical director during the peer to peer.

3 hours ago, BMC blogger said:

What am I doing wrong? Seeking advice, I’m 3 months post-op and have been in a 5lbs flux for over a month. Up and down, finally saw some movement last week when I forgot to take my Protein Shakes for a couple of days but as soon as I started them up again I gained. Has this happened to anyone?

I would schedule an appt with your dietitian or nutritionist asap. If you aren't already, make sure you log your food & exercise. That will help you & your Dr or nutritionist identify any areas of concern.

Once you finish your surgeons required testing then they will submit to insurance. They may have you do or you may have already done blood work, psych eval, esophageal test & an ekg. Authorization from insurance can take as little as a week on up to 30 days depending on you insurance.

Everyones journey is a little different. The hardest part of this process is being patient. Just stay the course and hopefully before you know it you'll be counting down the days til surgery.

4 hours ago, Taycakes said:

I am wondering how long it will take before actual surgery?

Depends on your surgeons schedule & availability of the hospital . You can call your surgeons office and ask if you were approved today, when are they currently scheduling.

Well good news is you're coming up on 3 weeks since being submitted so they should have a decision soon, especially since its been escalated now.

1 hour ago, sasa_maria said:

I did call and she said it didn't say.. Ugh! So frustrating. So I Googled it trying to see if someone else had keystone first and what they had to say.. I found something from 2011 saying that they didn't have one at all.. Who the hell knows. I'll have to ask to speak with a manager or something. It's so frustrating that noone can just give me a straight answer.. Even the people that work there.

Wow thats lame. Sounds like they are just reading your specific plan benefits but aren't looking at their policy overall. You could also ask to talk with a care manager, a nurse or someone from precert or pre-auth dept. What insurance do you have?

On 3/27/2018 at 7:16 AM, sasa_maria said:

I got a paper from my surgeons office saying according to my insurance I need 3 months of medically managed weight loss program but the insurance website says 6 months... So I called my insurance and she said it doesn't say for how long. Sweet baby Jesus someone help me here lol. I'm so frustrated. I thought this whole time I could have my surgery by June come to find out it could be in September... Anyone else have this problem?

Their are typically 2 programs insurances will accept.

One is a 3 month multi-disciplinary surgical preparatory regimen that includes behavior modification, nutrition/diet consults & exercise regimen. The second is a 6 month physician-supervised nutrition and exercise program.

So it may be that your insurance accepts both & you only need to complete one or the other. It may be that everyone is just miscommunicating. You can always call your insurance company and ask them for the policy on weight loss surgery. They will be able to provide it to you. You may even find it on their website.

I'm 2 weeks post-op & still on a full liquids, only 1/3 cup per meal. I know every surgeon has their own diet & nutrition plan to follow after, so just make sure you are following their guidelines. You said you had half of this, some of that, etc. Are you measuring your food?

You should definitely plan ahead & log your food & the amount you're eating. We don't have the luxury of eating whatever we feel like or crave anymore.

10 hours ago, Jumanna said:

 40 or over with one or more co-morbid conditions"

under the definitions tab they have this as a co-morbidity:

"Co-morbid conditions: Means for the purposes of the Bariatric Surgery benefit, the following chronic health conditions:  Cardiomyopathy  Type 2 Diabetes  Coronary Heart Disease  Hypertension  Gastroesophageal reflux disease (GERD)  Clinically significant obstructive sleep apnea"

I am afraid that since I do not have any of those conditions I will not get approval for my surgery. My mother's side of the family has a history of diabetes while my father's side has a history of heart disease and cholesterol.

Current weight: 285 BMI: 46

You're not being treated for high blood pressure (hypertension)? With a BMI of 46, you'd only need to meet one.

If you don't meet their criteria it is likely you won't be approved. Have you talked with your Dr, they may have a plan when submitting for approval.

Insurance standard is 30 days. Again its all dependent upon the clinicians workload & the number cases to be reviewed.

Good luck.

Most insurance companies will deny if you have a net gain in weight during the 6 month program. Best to double check with your insurance company on their policy.

On 3/26/2018 at 6:32 PM, Brttnyj89 said:

I know that I have posted this topic before, but the waiting is killing me! I am having a revision surgery, lapband to bypass. My paperwork was submitted to the insurance company on 03/14/2018. I have called every day since then asking about the status of the pre determination. I've been told that it takes up to 30 days. Has anyone had it approved in less than 30 days?

30 days is the insurance standard turnaround time. Yes, it can be approved before but it all comes down to the amount of cases the clinicians have to review. Of course if there is any missing clinical info that can delay the process.

On 3/24/2018 at 10:52 AM, sammi123 said:

I do have $750 deductible. So my copays will go towards this? I am confused.

No, copays do not apply to the deductible. They will apply to an out of pocket maximum if your plan has one. You'll have to check your plan details to be sure.

I had surgery 3/23 & will be off for 3 weeks.

I was surprised to see that some people went back so soon. That must be difficult. I know everyones circumstances may vary but I can't imagine going back that soon. One week out & I'm still getting to know my limitations & adjusting.

Approval/coverage is based on your specific plan benefits & medical necessity. First I'd recommend calling Aetna to ask if it is covered under YOUR plan. Second, read their policy on bariatric surgery to find out what is covered & what criteria needs to be met. If your plan covers a revision & your medical records show that you meet their criteria then you shouldn't have an issue getting approved.