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Denied after being approved and devastated



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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

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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...

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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

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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.

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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.

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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!

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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.

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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.

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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.

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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 ?

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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...

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Thanks for the update. Sounds positive. Good luck!

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

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