Jump to content
×
Are you looking for the BariatricPal Store? Go now!

Denied after being approved and devastated



Recommended Posts

This must be new, I had surgery last year and the hospital and clinic I went to is not on their list. What a shame, it is a great and comprehensive program.

Plus, really Northwestern isn’t good enough?

Northwestern Delnor

Share this post


Link to post
Share on other sites

13 minutes ago, Cheeseburgh said:

This must be new, I had surgery last year and the hospital and clinic I went to is not on their list. What a shame, it is a great and comprehensive program.

Plus, really Northwestern isn’t good enough?

Northwestern Delnor

mayo Clinic, too. Seriously? Mayo is one of the best hospitals in the world...

Share this post


Link to post
Share on other sites

I’m not so sure how cut and dry this is, my surgeon is listed when I looked under surgeons vs Bariatric Clinics. He even has a special designation listed.

602F4266-6127-4014-823D-854823AD53BD.png

Share this post


Link to post
Share on other sites

2 hours ago, Cheeseburgh said:

I’m not so sure how cut and dry this is, my surgeon is listed when I looked under surgeons vs Bariatric Clinics. He even has a special designation listed.

602F4266-6127-4014-823D-854823AD53BD.png

It's all so confusing. My surgeon is listed for Aetna and is covered, but the hospital he does his surgery at is not covered. It's in network but doesn't have IOQ designation. sooo..I had an upper GI performed there but I can't have a bariatric surgery there. And my surgeon won't go to any other hospital. ARGHHHHH makes no sense.

Share this post


Link to post
Share on other sites

14 hours ago, Panda333 said:

I have to get this off of my chest. I'm not super active posting but have read a lot. Here is my story. I have terrific Aetna insurance. I originally wanted to go to the mayo clinic for my surgery but I found out that AETNA needs a facility to be an institute of Quality (IOQ) So mayo clinic wouldn't take me on. Even though I called Aetna and have a letter saying it doesn't need to be an IOQ. Fast forward I found another surgeon, who is not an IOQ but a Center of excellence. They checked with Aetna and said I was covered and signed me up for their program in April. The past four months i've gone through all the steps, the psychologist, chest xrays , upper GI, Cardiac clearance and radiological stress trest, 3 nutrition appointments and weigh ins 60 miles away. 3 check ins with my PCP for weigh ins... oh and my back was thrown out in the middle of this.

I completed all steps and the advocate states today I was denied because they are not in institute of quality but a center of excellence. What?? We checked on this. Then she starts to give me other hospital names. wait..no......WTF. I'm sort of mad at my surgeons office but also Aetna. They said it doesn't matter what they said in writing, they won't cover me because my doctor is not an IOQ. I'm devastated and frankly wish I would have gone to Mexico to begin with. I've already spend more money out of pocket than the surgery would be in mexico. nonsense.

needed to vent

All your test results should transfer over to your new program. I had a similar experience with my insurance and was very near quitting but managed to hold on and finally almost a year and a half later got my surgery. Hang in there, it's worth the frustration.

Share this post


Link to post
Share on other sites

14 hours ago, Panda333 said:

Yes, my deductible is paid up! going to try to appeal but then maybe will take my files as others have suggested. Frustrating because I had bonded with my surgeon, etc.

I wouldn't even bother with trying to appeal their decision. You will end up losing your appeal anyways and become even more frustrated. I'd get all your records immediately and go to an approved surgeon. If you waste time trying to appeal their decision you're going to end up having to start all over again!

Share this post


Link to post
Share on other sites

On 8/28/2019 at 8:15 AM, Panda333 said:

I have to get this off of my chest. I'm not super active posting but have read a lot. Here is my story. I have terrific Aetna insurance. I originally wanted to go to the mayo clinic for my surgery but I found out that AETNA needs a facility to be an institute of Quality (IOQ) So mayo clinic wouldn't take me on. Even though I called Aetna and have a letter saying it doesn't need to be an IOQ. Fast forward I found another surgeon, who is not an IOQ but a Center of excellence. They checked with Aetna and said I was covered and signed me up for their program in April. The past four months i've gone through all the steps, the psychologist, chest xrays , upper GI, Cardiac clearance and radiological stress trest, 3 nutrition appointments and weigh ins 60 miles away. 3 check ins with my PCP for weigh ins... oh and my back was thrown out in the middle of this.

I completed all steps and the advocate states today I was denied because they are not in institute of quality but a center of excellence. What?? We checked on this. Then she starts to give me other hospital names. wait..no......WTF. I'm sort of mad at my surgeons office but also Aetna. They said it doesn't matter what they said in writing, they won't cover me because my doctor is not an IOQ. I'm devastated and frankly wish I would have gone to Mexico to begin with. I've already spend more money out of pocket than the surgery would be in mexico. nonsense.

needed to vent

Hey, I can feel ya. I went to my appointment today to have my first consult with the bariatric surgeon, ands I too was denied. After all the research I have done and gone through the bariatric seminar bcuz I had to have the seminar b4 seeing the surgeon. But bcuz my BMI is not high enough or the fact that I am not a full blown diabetic, I got denied. He offered me t he ballon which is a temporar solution for 6 months, but after 6 months it has to be removed & there is a chance of me gaining my weight back. WTF! I don't wanna gain my weight back, I wanna lose it for sake . I have no willpower to lose it on my own bcuz if there is ice cream or Cookies around ( as my husbands Snacks on them) it will entice me to eat it as well when I want something sweet even if there is fruit around.

Share this post


Link to post
Share on other sites

11 minutes ago, Chattanoogagirl said:

I don't wanna gain my weight back, I wanna lose it for sake . I have no willpower to lose it on my own bcuz if there is ice cream or Cookies around ( as my husbands Snacks on them) it will entice me to eat it as well when I want something sweet even if there is fruit around.

Sorry to bear bad news, but seriously, the surgery is a tool. They operate on our tummies. It does NOTHING for our mind. :( I really encourage you to see a counselor and start working through your food issues and compulsive eating. You will have way more long term success with or without surgery. Also having a local support group--maybe even look into OA?

In the past 2 1/2 years (actually much longer than that), but that's how long I've been pursuing this new WLS life (the lead up, surgery and post surg life), I've had to work continuously on developing new habits with food. And relationships. I have had to amend how we stock our pantry, fridge, and freezer and had to also work to get Mr. F. on board with living a healthy life.

I believe that's what most are gonna need in order for long term success. I don't believe in the myth of restriction and malabsorption, nor do I depend on it.

Share this post


Link to post
Share on other sites

On 8/29/2019 at 8:33 AM, kathy060464 said:

I wouldn't even bother with trying to appeal their decision. You will end up losing your appeal anyways and become even more frustrated. I'd get all your records immediately and go to an approved surgeon. If you waste time trying to appeal their decision you're going to end up having to start all over again!

Hi Guys, I'm the original poster and I have an update. i sooo appreciate everyones comments. You have helped me more than you know. I hear you about not bothering to appeal but my sense of justice is rearing it's head, lol. I'm so mad and am just going to give it one more shot. I called Aetna and found a special concierge associated associated with my company. I work for a company with 50,000 employees worldwide. They actually found the paperwork where they originally told me the "IOQ" was not required. They seem to want to help me to get this surgery. I also think they are embarassed I've already spend $4200 out of pocket just on my pre surgery stuff. I also wrote a firm e-mail to the business office about how shocking it is for them to give up on this so easily and dismiss me as a patient and how it's bad for business. I copied in my surgeon. The Surgeon, who is amazing, called me back right away and told me he he has been made aware and the hospital's office is doing everything they can. He said even if they end up not covering they will help me find another surgeon. He even took the time again to talk to me about the surgical options and thinks I'll have better results with bypass, due to finding out I have some GERD on the upper GI.

Anyway....more to come. I feel like I made a little traction yesterday.

Share this post


Link to post
Share on other sites

Now my friends, now you all know. what engenders the sarcastic motto: "AETNA- I wish I had never met ya! " I can only hope there is Special area in Hades for health insurance executives to be placed in . Then when they start screaming for mercy ,we can say " Gee, I'm sorry , but YOU DON'T QUALIFY, and we don't have the time to examine your problem on a case- by- case formula or subject you to,peer review." Yeah, never would happen but I can dream, can't I ?

Share this post


Link to post
Share on other sites

Hello, I'm the original poster - Latest update. Well last week I raised such cane with my dr's office and the insurance company. I decided to take control rather than let them rule my life. Today I get a call from the insurance company. They received my appeal and did research. it turns out there were some errors in the plan docs which caused confusion. They said "Congratulations!" I am covered and it DOES not have to be an IOQ, although they prefer it. Whoo hoo. But then they told me I had to get with my dr's office to tell them to resubmit with the clinical information showing I went through all of the steps. So I happily sent an e-mail to the business office and told them what to do. I blind copied in my surgeon because I just don't trust them.....(They were so quick to give up on me) I told them to kindly re-submit and gave them the person's name (RN) to reference. I basically hand delivered their job.....happy, I went on with my day....

then......... 5 minutes later........

The insurance lady I just spoke to called me back...and said...Oh I meant to tell you..... I did mention your surgeon and hospital doesn't have to be an IOQ but if an IOQ is available in your geographic area you have to use them. I went to my handy google maps. IOQ is 6 miles from my house but the surgeon I selected and have already paid $4200 is 28 miles. So.....I guess there is a chance insurance could deny again.. The funny thing is when I was first searching for doctors, I checked out Orlando Health (the IOQ) and they never called me back.....

arghhhhh...the confusion and agony of waiting. Meantime the hurricane was coming and i have been stress eating here in Florida.

Thanks for listening...

Share this post


Link to post
Share on other sites

Hang in there.

Share this post


Link to post
Share on other sites

Thanks for the update. Sounds positive. Good luck!

Share this post


Link to post
Share on other sites

Oh geez...I hope you can get that money back.

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • Prdgrdma

      So I guess after gastric bypass surgery, I cant eat flock chips because they are fried???  They sell them on here so I thought I could have them. So high in protein and no carbs.  They don't bother me at all.  Help. 
      · 1 reply
      1. NickelChip

        It's possible for a very high fat meal to cause dumping in some (30% or so) gastric bypass patients, although it's more likely to be triggered by high sugar, or by the high fat/high sugar combo (think ice cream, donuts). Dietitians will tell you to never do anything that isn't 100% healthy ever again. Realistically, you should aim for a good balance of protein, carbs, and fat each day. Should you eat fried foods every day? No. Is it possible they will make you sick? Maybe. Is it okay to eat some to see what happens and have them for a treat every now and again? Yes.

    • NovelTee

      I'm not at all hungry on this liquid pre-op diet, but I miss the sensation of chewing. It's been about two weeks––surgery is in two days––and I can't imagine how I'll feel a couple of weeks post-op. Tonight, I randomly stumbled upon a mukbang channel on YouTube, and it was strangely soothing... is it just me, or is this a thing? 
      · 1 reply
      1. NickelChip

        I actually watched cooking shows during my pre-op, like Great British Baking Show. It was a little bizarre, but didn't make me hungry. I think it was also soothing in a way.

    • Clueless_girl

      How do you figure out what your ideal weight should be? I've had a figure in my head for years, but after 3 mths of recovery I'm already almost there. So maybe my goal should be lower?
      · 3 replies
      1. NickelChip

        Well, there is actually a formula for "Ideal Body Weight" and you can use a calculator to figure it out for you. This one also does an adjusted weight for a person who starts out overweight or obese. https://www.mdcalc.com/calc/68/ideal-body-weight-adjusted-body-weight

        I would use that as a starting point, and then just see how you feel as you lose. How you look and feel is more important than a number.

      2. Clueless_girl

        I did find different calculators but I couldn't find any that accounted for body frame. But you're right, it is just a number. It was just disheartening to see that although I lost 60% of my excess weight, it's still not in the "normal/healthy" range..

      3. NickelChip

        I think it's important to remember that the weight charts and BMI ranges were developed a very long time ago and only intended to be applied to people who have never been overweight or obese. Those numbers aren't for us. When you are larger, especially for a long time, your body develops extra bone to support the weight. Your organs get a little bigger to handle the extra mass. Your entire infrastructure increases so you can support and function with the extra weight. That doesn't all go away just because you burn off the excess fat. If you still had a pair of jeans from your skinniest point in life and then lost weight to get to the exact number on the scale you were when those jeans fit you, chances are they would be a little baggy now because you would actually be thinner than you were, even though the scale and the BMI chart disagree. When in doubt, listen to the jeans, not the scale!

    • Aunty Mamo

      Tomorrow marks two weeks since surgery day and while I'm feeling remarkably well and going about just about every normal activity, I did wind up with a surface abscess on on of my incision sights and was put on an antibiotic that made me so impacted that it took me more than two hours to eliminate yesterday and scared the hell out of me. Now there's Miralax in all my beverages that aren't Smooth Move tea. I cannot experience that again. I shouldn't have to take Ativan to go to the lady's. I really looking forward to my body getting with the program again. 
      I'm in day three of the "puree" stage of eating and despite the strange textures, all of the savory flavors seem decadent. 
      I timed this surgery so that I'd be recovering during my spring break. That was a good plan. Today is a state holiday and the final day of break. I feel really strong to return to school tomorrow. 
      · 0 replies
      1. This update has no replies.
    • BeanitoDiego

      Now that I'm in maintenance mode, I'm getting a into a routine for my meals. Every day, I start out with 8-16 ounces of water, and then a proffee, which I have come to look forward to even the night before. My proffees are simply a black coffee with a protein powder added. There are three products that I cycle through: Premier Vanilla, Orgain Vanilla, and Dymatize Vanilla.
      For second breakfast on workdays, I will have a low-fat yogurt with two tablespoons of PBFit and two teaspoons of no sugar added dried cherries. I will have ingested 35-45 grams of protein at this point between the two breakfasts, with 250-285 calories, and about 20 carbs.
      For second breakfast on non-workdays, I will prepare two servings of plain, instant oatmeal with a tablespoon of an olive oil-based spread. This means I will have had 34 grams of protein, 365 calories, and 38 carbs. Non-workdays are when I am being very active with training sessions, so I allow myself more carbohydrate fuel.
      Snacks on any day are always mixed nuts, even when I am travelling. I will have 0.2 cups of a blend that I make myself. It consists of dry roasted peanuts, cashews, pumpkin seeds, sunflower seeds, pistachios, and Brazil nuts. This is 5 grams of protein, 163 calories, and 7 carbs.
      Breakfast and snacks have been the easiest to nail down. Lunch and dinner have more variables, and I prepare enough for leftovers. I concentrate on protein first, and then add vegetables. Typically tempeh, tofu, or Field Roast products with roasted or sautéed vegetables. Today, I will be eating leftovers from last night. Two ounces of tempeh with four ounces of roasted vegetables that consist of red and yellow sweet peppers, sweet potatoes, small purple potatoes, zucchini, and carrots. I will add a tablespoon of olive oil-based spread, break up 3 walnuts to sprinkle of top, and garnish with two tablespoons of grated Parmesan cheese. This particular meal will be 19 grams of protein, 377 calories, and 28 grams of carbs. Bear in mind that I do eat more carbs when I am not working, and I focus on ingesting healthy carbs instead of breads/crackers/chips/crisps.
      It's a helluva journey and I'm thankful to be on it!
       
      · 0 replies
      1. This update has no replies.
  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×