Stuck with Aetna until Nov 2006

[Mystyblu 0]

About six months ago I decided to give myself a second try at getting approved for the lap band surgery. I knew that my ins would be difficult. Aetna POS (piece of sh!t). No one told me they change the rules in mid stream. When I first visited AIGB they gave me a list of all of the tests and documentation I needed to have in order to get my approval. I completed them all except the 6 months of Dr. supervised weight loss. I visited my PCP and she was more than willing to assist me. In November I called AIGB to let them know I had 1 month left for the dr supervision and they let my know that I had been approved by Aetna and I need to schedule with Dr. Powell’s office. I was so excited that I could possible be getting my band by the end of the year.

I called the dr’s office and let them know what AIGB said and they stated they would have my file faxed over to them from AIGB. I called a couple days later to insure they had gotten my file which they had and the insurance coordinator was getting all the paperwork to the ins company. November came and went with no word from the Dr’s office. November is also open enrollment for insurance. I didn’t want to change my coverage because I had already been approved. I thought why change and have to start all over. I started calling Dr. Powell’s office to see where we were on getting my appointment scheduled. I was told my file was with the insurance coordinator. I called and left several messages for her and after 3 weeks today I was finally able to talk to her. She started listing several co morbidities I had never heard of before. And said without one of them I would probably not be approved. I told her that no one had ever told me about these before. She said that I should call Aetna and find out what pre-qualifications were needed for lap band surgery. (isn’t that her job??). I don’t want to say that she was disinterested but that’s the way I felt. I felt like I was alone in this.

I called Aetna and talked to a very nice member assistant. She told me that my company’s policy did cover the lap band surgery. She also gave me an 800 and said that the dr’s office can call that number and get all the information needed. She also looked at my file and stated that no one had called or sent any information regarding surgery or pre-qualification. So the ins coordinator had not even tried to get an approval. What exactly has she been doing for over a month and a half?? I called the Aetna 800 # to see if they would give me the info. They wouldn’t. She just directed me the www.aetna.com. To my discovery their guidelines have changed. I have met, or exceeded, the requirements for RYGB but in order to get the lap band the following is required.

Vertical Banded Gastroplasty (VBG) and Laparoscopic Adjustable Silicone Gastric Banding (LASGB or Lap-Band):

Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) or laparoscopic adjustable silicone gastric banding (LASGB, Lap-Band) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following co morbid medical conditions:

1. Hepatic cirrhosis with elevated liver function tests; or
   
2. Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or
   
3. Radiation enteritis; or
   
4. Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or
   
5. Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV) (see Appendix).

http://www.aetna.com/cpb/data/CPBA0157.html

I DON’T have any of these. These were NOT listed 6 months ago. This information had defiantly let the wind out of my sails. The woman in the Dr’s office seems unwilling to even submit the request let along willing to help me fight for approval. I qualify for RYGB but that is not the surgery I want. Do I try another Dr’s office that is more willing to help?? Would that require starting over again? Open enrollment doesn’t come around again until November 2006. Where do I go from here? I feel like I am so close but I don’t know what I can do next or where to look for help. Just feeling rather defeated and outdone,

Oh gosh, didn’t mean to talk so long. Thanks for listening to my rant. Any words of encouragement would be grateful.

[Alexandra 55]

Hey Mysty,

I totally feel your pain, been there, done that. Don't give up--there are things you can do to salvage the situation, and if in fact you have to wait until November of 2006 you will be amazed at how fast that comes around. I was in a similar situation, fighting Aetna while waiting for a chance to change carriers, and I beat Aetna before open enrollment came around. Now THAT is satisfying!! So don't just sit and mope, see what you can do in the meantime.

First, what is AIGB, and who told you you were approved in the first place?

Second, the information on Aetna's website is general medical policies, not a hard-and-fast determination of any given person's medical situation. They are saying, essentially, that obesity surgery is covered for people who qualify medically (which you do, so that's good), but that their preferred procedure is RNY (which you don't want, so that's bad).

They list SOME specific reasons why banding would be preferable over RNY, but that is not an exhaustive list. You and your doctor must have come to the conclusion that banding is medically preferable for you, so you should try to make a persuasive argument as to why that is. Check out the thread called "Just Starting to Explore My Options..." in the Insurance section and you'll find my appeal letter, which had to make the exact same argument. When I appealed banding was completely excluded for ANY reason, so I had to cover some additional bases, but the basic point was that RNY was not medically preferable for me.

If your doctor is not on board you may want to try someone else. But it's always worth submitting that request for precert and getting the denial so you can see specifically what you have to fight against. You haven't even gone that far at this point, right? So you don't even know IF you're going to be denied?

Don't assume anything. You've come a very long way and had all the testing done, so go ahead and pull your material together and have your doctor submit the request. You might be surprised. You are seeking necessary medical treatment, not shopping for a new dress, so show them you're taking it seriously. I had to pester my surgeon's office to get the request submitted because they knew I'd be denied--which I was--but that is a crucial first step before you can mount an appeal. So don't give up!! At the very worst you will have to wait until next November when you can choose another carrier. I waited just about a year too, and don't regret it at all (though it was hard at the time, definitely).

Good luck!! And please let us know how it's going--I really want to see Aetna fold on their absurd preference for RNY, a vastly more expensive, risky, and drastic treatment.

[DrHekier 0]

Vertical Banded Gastroplasty (VBG) and Laparoscopic Adjustable Silicone Gastric Banding (LASGB or Lap-Band):

Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) or laparoscopic adjustable silicone gastric banding (LASGB, Lap-Band) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following co morbid medical conditions:

1. Hepatic cirrhosis with elevated liver function tests; or
   
2. Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or
   
3. Radiation enteritis; or
   
4. Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or
   
5. Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV) (see Appendix).

http://www.aetna.com/cpb/data/CPBA0157.html

What I always found interesting with Aetna's requirement is that the FDA does NOT approve the Lap Band being put in patients with

1) Patients with cirrhosis or

2)Inflammatory bowel disease (see http://www.fda.gov/cdrh/pdf/P000008b.pdf);

and surgeons may not choose to electively place the Lap Band in patients with conditions 3, 4 and 5.

I will leave each to draw their own conclusions with regards to Aetna and their policy on Lap Bands

[Aimze 0]

I am not a fan of Aetna myself. It took me one year from the time of my first consult until I was approved for banding.

I fought so hard. Called senators and surgeon General and everyone who would listen. No one could help. So I got a lawyer. That helped after 3 appeals I was approved. DO NOT GIVE UP! They can not tell you what kind of surgery you can have. If you are approved for RNY then you should be able to get the band. Keep fighting. They make it so hard in the hopes that you give up and go away. Don't forget the old saying " The squeaky wheel gets the oil" Squeak my friend, SQUEAK!

Good luck to you

Amy

[NanaRenan 0]

I found this thread when I did a search on "adhesions".

How exactly do they determine if a person has adhesions without actually doing surgery to see...?

Does prior surgery for adhesions (like 14 years ago) suffice to qualify one now?

I have Aetna and ran into their wall of requirements. I called the hospital where I had surgery in 1992 and had my records sent to me, they clearly state that multiple adhesions were lysed during that surgery.

I'm faxing it to my doctor's office tomorrow. I hope to hear something soon. Insurance enrollment is in February!!

Any insurance companies that are pushovers at approving lapband...?

[ReneBean 3]

**Hey Mysti -

I am not a huge fan of AIGB (Alex, AIGB coordinates the medical testing for Surgery Center of Richardson) - but what they told you was that you were MEDICALLY approved - in other words - you physically qualify according to them to have the surgery. SCOR has an assembly line thing going on - which must be working for somebody - but not for you, or for me, either.

AIGB Medically Approved me and then forwarded my file to LapBand Solutions - who handles the insurance approvals. LBS submitted my file and I was denied. After that, I took over.

I have Blue Cross - and they have their own little barrel of monkeys for getting approval if you happen to have a high BMI (like me). Call whoever has your file and tell them that if they don't submit your package to Aetna right now, you will happily come and pick it up and find another surgeon. If that doesn't get some action - DO IT. There are plenty of qualified surgeons here in DFW and I would hazard a guess that most if not all of your tests are 100% transferable to another physician. Certainly, the 6 mos of diet history with your PCP will be.

Once your file is submitted and you get that first denial - YOU will have control over the fight. Don't wait for LBS (or anyone else) to help you - I would STILL be waiting these four months later - but start calling Aetna and asking pointed questions and figure out just what you have to do.

I am waiting for the State of California to complete an independent medical review. Hopefully, this will overturn the denials I have received. I am keeping the faith that sanity will prevail.

Keep your chin up!

[Alexandra 55]

ReneBean, you are a woman after my own heart! I hope like hell you prevail on external review, like I did. Every time one of us does, it chips away a tiny bit away on the wall of insurance industry resistance. Good on you!!!

[Mystyblu 0]

Just a quick note to keep you up to date on my approval process. I called Dr. Powell's office back just after the new year. I think the ins coordinator had a good new years becuse she seemed much more willing to help. She gave me a short list of things that were missing from my file like my nutritionist visit and previous medical records and report from my current PCP. I have contacted all my previous Dr's offices (the ones I can remember) and requested my medical records sent. Once the coordinator gets all the reports and records she will submit the information to Aetna. If I get approve it GREAT, WONDERFUL but if I don't I plan to whole heartedly fight it.

I will not give them the satisfaction of denying me the life I need, want and deserve.

[ReneBean 3]

I got my denial by Blue Cross overturned. Power to the People!!

[Mystyblu 0]

I got my denial by Blue Cross overturned. Power to the People!!

CONGRATULATIONS!!!! Good for you.

[Alexandra 55]

Mysty, are you in California? If so, the same external review process that Renebean used might work for you as a last resort, if necessary. Don't give up!! :whoo:

[Mystyblu 0]

Alex~

I am in Dallad Texas. I am still getting all of my info together. Now I need 5 years of medical history. I have to remember every doctor I have visited in the last 5 years and request my medical recored. I think I have just one more to go. I plan to keep going no matter how much stuff they keep asking for. But I have to tell ya, its getting awfully daunting.

[MissyN 0]

Aetna changed their requirements in March 2006 and now do not require those listed in a previous post. I was approved on the first try with 37 BMI and sleep apnea.

[mousecrazy 2]

Fantastic!

This is always great news!

[bobimport 0]

Well I tried for 8 mo to get approved and when June 1 came around Aetna dropped the coverage for Fl. Bass and Cohen screwed around for 3mo and did not file the paperwork. Aetna only costs me $1400 a mo for a familey of 4.

Bob