I have all the cormobidities to be able to be approved ... But I have been denied 6 times. Going thru the appeals dept. We have appealed over and over. I lost hope in this surgery center. I am currently switching to a new surgeon. To see if they can get me approved. Any tips or advice for allied/Aetna insurance ppo. State of Cali.

Oh wow, I'm so sorry!

Did they tell you specifically why they keep denying you? Or is it an exclusion against bariatric surgery?

Yea. Because of exclusions. In their insurance book which I read. It states the exclusions but also states that if a person is 100 over weight. Diabetic. And other things such as sleep apnea which I have. They would cover surgery.

I took that page scanned it and had it sent with highlighted parts. Lol reminding them what their book says. But I don't think the appeals dept. Sent it in.

I have Atena in Louisiana and I fall under the morbid obesity guidelines. It's very interesting to have read you post because I have an appointment with my Dr in two weeks to see if the insurance conpany will prequalify me for the surgery. If so I know they will cover 85% of the cost. Please keep me updated and I will keep you up to date on my approval process.

I was pre-approved for my surgery before starting the 6 month supervised weight loss. Upon completion of the supervised weight loss program and preparing to move forward with the surgery, they have declined me stating 1) I don't have valid comorbidities even though the comordities I have were pre approved 2) I didn't lose enough weight during the 6 month weight loss program.

Good Luck to you!

Yea. Because of exclusions. In their insurance book which I read. It states the exclusions but also states that if a person is 100 over weight. Diabetic. And other things such as sleep apnea which I have. They would cover surgery.

I took that page scanned it and had it sent with highlighted parts. Lol reminding them what their book says. But I don't think the appeals dept. Sent it in.

What is the exclusion they're trying to deny you for?

I seriously hate insurance companies. I see stuff like this all the time and it's frustrating as heck. It's like, they'd rather pay hundreds of thousands of dollars over years for obesity related illnesses than a quarter of the cost to get the WLS and hopefully cure the obesity. It makes zero sense.

This is the time you find out how much you really want it! My insurance company also excluded the surgery. I worked 3 jobs for over a year to save enough to get the surgery! It's kind of like the band philosopy, you cant wait for the band to do it for you. You also can't wait for the insurance company. If they continue to decline you, what do you plan on doing? Have a plan! Anything worth having is worth working for! Trust me I understand the frustration, we pay over $2300.00 a month for insurance and it sucks it's not covered. However, if you feel your life is in jeopardy if you don't have the surgery you can't just throw your hands in the air if the insurance company won't pay. Come up with plan B! Good luck, I hope it all works out for you!

Did they send you anything in writing? If not I would ask for something so you can see what the reasons are behind the denial. Get someone who is very experienced and has been successful with appeals. Many years ago I worked for a psychiatric practice and my department manager was really good at that. Our practice never lost an appeal that we took on for our patients and when she went to get Bariatric surgery (I don't know what kind it was since it was way before lap band and stuff) she was denied, took on her own appeal and won! Do some research and then go at them with guns blazing! Good luck. Sometimes I think approval/denial depends upon who is in charge of that department in that region and you may have to go above them.

I had Aetna POS (in TX) at the time of my surgery and didn't have any problems. I had a 4 month waiting period in which I was supposed to lose weight and I actually gained Once I was approved a nurse calls me every so often to check on my progress, offer suggestions and to make sure the surgery center was treating me well. I'm actually disappointed that since then we had to change insurance companies.

Good luck!

I have Aetna also (NJ). I was denied twice. The 1st time because of "missing documentation". They said that they didn't have proof of 3 yrs of high BMI. Obtained and sent my gynecological medical records which had weight notes. Following that they denied because the records showed my BMI was 39.8 and my co-morbidity of Hypertension was "well-controlled without a lot of medicines" (great grammar-lol). My surgeon then requested a peer-to-peer review. 1 week before that conference was scheduled, I received a letter saying that they had (inexplicably) reversed their decision! My Dr. believes that it had to do with it being the end of the calendar year ( Nov. 2012). He has had better success at either the end of the year or the beginning.

Sorry for the long story but definitely don't give up! Encourage your surgeon to schedule a peer-to-peer. They have a harder time denying then.