Denied after being approved and devastated

[KishaG 61]

On 8/28/2019 at 4:39 PM, 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.

TBH I wouldn't even bother with an appeal, just get all your records and go to a new Dr. As I was reading your post my very first thought was why would they not allow mayo Clinic due to the IDQ, but take this other clinic even though they aren't IDQ it sounds really sketchy to me.

[Sheribear68 3,200]

On 08/28/2019 at 10:15, 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

Wow. Just found this.
I too have Aetna and they did a VERY similar thing to me.
Thankfully I found out they weren’t going to cover my initial place just 3 months into the process, but I had to start all over again right around this time last year.
I started right after July 4th at bariatric clinic #1 last year and had to switch in late September and then didn’t get approved until mid-January 2019. Had surgery on 2-6-19 (7 months after starting the journey) and I felt so “behind” and “cheated” of time.
There are still days where I tell myself that I’d be at goal by now if I’d only been able to have my sleeve in early November 2018, but the important thing is I got there eventually.


Hang in there, do the steps, and take advantage of the extra time to research and work on your head game before surgery day.

[Panda333 275]

8 minutes ago, Sheribear68 said:

Wow. Just found this.
I too have Aetna and they did a VERY similar thing to me.
Thankfully I found out they weren’t going to cover my initial place just 3 months into the process, but I had to start all over again right around this time last year.
I started right after July 4th at bariatric clinic #1 last year and had to switch in late September and then didn’t get approved until mid-January 2019. Had surgery on 2-6-19 (7 months after starting the journey) and I felt so “behind” and “cheated” of time.
There are still days where I tell myself that I’d be at goal by now if I’d only been able to have my sleeve in early November 2018, but the important thing is I got there eventually.


Hang in there, do the steps, and take advantage of the extra time to research and work on your head game before surgery day.

Thank you for sharing your story. I'm growing weary. Yes, I'm still in the fight and it feels like I'm doing my dr's office job for them too. Last ditch, I got my employer HR advocate on the case. At least i know I did everything I could do....I've just 100% completed everything and I cannot bear to start over. And I'm in the middle of a job change so who knows what my insurance will be. I'm hanging on to the job I hate because I want this insurance thing to play out. I'm miserable fighting this. I looked today at our insurance plan documents and there is nothing about IOQ even today. It's unfair that they put this on their super secret plan documents. I have two letters from them staying IOQ not required as well. hanging in here for now but will switch courses soon....

[Frustr8 7,886]

You have both my sympathy and empathy . I started my own journey August 15 2015, finally had my RNY surgery September 5th 2018, after I went through Surgeon #1 ' s program not once but twice, lost my job 5 months in so had to Do Everything a Second time with different insurance coverage, then He Had the Audacity to "kick me to the curb" because He No Longer had desires to perform My Surgery. Had to re-group, find a Surgeon worthy of my Trust, 6 months after enrolling I had my long-desired Surgery at the Age of 72 years 8 months 10 days, It Really Was A Day of Rebirth, made my life Turn Good and I will never regret all that went BEFORE. because it made Me strong, it made healthier, it made Me one-half the size I once was- annd my life will be longer, my Future brighter and I can only wish such good things happen for YOU TOO! But No Matter What- You have a Friend and Admirer in ME!

[Sweettoothless 100]

Panda make sure you go to your monthly weigh-in with your doc or wherever you have been going if it is required to do x amount of monthly weigh ins because many ins companies demand they be CONSECUTIVE monthly appts. My pcp stressed that to me. And some months for me were wonky due to my docs vacay schedule or mine. Like making my july appt and then 2 weeks instead of 4 later doing my August appt.

[AZhiker 2,251]

On 8/29/2019 at 10:19 AM, Chattanoogagirl said:

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.

Get tested for sleep apnea. I did not even know I had extreme sleep apnea until I was tested. Since I was not diabetic, either, this gave me the diagnosed co-morbidity to nail in my borderline BMI.

[darcyjae 106]

You may want to check again. I saw that they changed the indications for surgery yesterday, lowering the recommendations for BMI.

[Panda333 275]

***Update***

Guys, I’m so happy I could cry. After really going full scorched earth/raising Cane with Aetna, my dr.s office, and with my employer, I found out today I’m approved. I really can’t believe it. Still don’t have a date but this is fantastic news. Thanks Everyone and I’ll be seeing you online here with probably more questions.

It was not easy, had to complain to the business office supervisor, the surgeon directly, I saved all of my correspondence and had an extensive timeline for everything and named everyone I spoke with at Aetna. If they approved me only to shut me up, I’ll take it.

This from getting initial “Sorry you are denied come pick up your paperwork”. I found out my advocate didn’t know how to file and appeal and that’s why she told me that.

[Panda333 275]

On 9/10/2019 at 8:04 PM, Frustr8 said:

You have both my sympathy and empathy . I started my own journey August 15 2015, finally had my RNY surgery September 5th 2018, after I went through Surgeon #1 ' s program not once but twice, lost my job 5 months in so had to Do Everything a Second time with different insurance coverage, then He Had the Audacity to "kick me to the curb" because He No Longer had desires to perform My Surgery. Had to re-group, find a Surgeon worthy of my Trust, 6 months after enrolling I had my long-desired Surgery at the Age of 72 years 8 months 10 days, It Really Was A Day of Rebirth, made my life Turn Good and I will never regret all that went BEFORE. because it made Me strong, it made healthier, it made Me one-half the size I once was- annd my life will be longer, my Future brighter and I can only wish such good things happen for YOU TOO! But No Matter What- You have a Friend and Admirer in ME!

Wow, what a story and thank you for sharing!

[rs 1,473]

***Update***

Guys, I’m so happy I could cry. After really going full scorched earth/raising Cane with Aetna, my dr.s office, and with my employer, I found out today I’m approved. I really can’t believe it. Still don’t have a date but this is fantastic news. Thanks Everyone and I’ll be seeing you online here with probably more questions.
It was not easy, had to complain to the business office supervisor, the surgeon directly, I saved all of my correspondence and had an extensive timeline for everything and named everyone I spoke with at Aetna. If they approved me only to shut me up, I’ll take it.

This from getting initial “Sorry you are denied come pick up your paperwork”. I found out my advocate didn’t know how to file and appeal and that’s why she told me that.

Great news!! So happy all your hard-fought efforts were a success!!

[Deedee12 1,859]

***Update***

Guys, I’m so happy I could cry. After really going full scorched earth/raising Cane with Aetna, my dr.s office, and with my employer, I found out today I’m approved. I really can’t believe it. Still don’t have a date but this is fantastic news. Thanks Everyone and I’ll be seeing you online here with probably more questions.
It was not easy, had to complain to the business office supervisor, the surgeon directly, I saved all of my correspondence and had an extensive timeline for everything and named everyone I spoke with at Aetna. If they approved me only to shut me up, I’ll take it.

This from getting initial “Sorry you are denied come pick up your paperwork”. I found out my advocate didn’t know how to file and appeal and that’s why she told me that.

Congratulations!!!!! If your tenacity is anything to go by, weight loss post OP better beware!!!!![emoji122][emoji122][emoji122][emoji122][emoji122][emoji122][emoji106][emoji106][emoji106][emoji106][emoji112][emoji112][emoji112]

Sent from my SM-N960U using BariatricPal mobile app

[ummyasmin 1,603]

Oh fantastic!!!!! Yayyyy

[Krimsonbutterflies 661]

Wonderful

[Frustr8 7,886]

And @ Panda333, I'm very proud you beat them at their own warped game-- after Fighting and Struggling through the Swamp of Insurance I am SO proud you now are swimming strongly towards Surgery. Keep us updated, and We Will Celebrate With You when it FINALLY HAPPENS!

[Mj77803 82]

On 09/12/2019 at 11:29, Panda333 said:

***Update***

Guys, I’m so happy I could cry. After really going full scorched earth/raising Cane with Aetna, my dr.s office, and with my employer, I found out today I’m approved. I really can’t believe it. Still don’t have a date but this is fantastic news. Thanks Everyone and I’ll be seeing you online here with probably more questions.

It was not easy, had to complain to the business office supervisor, the surgeon directly, I saved all of my correspondence and had an extensive timeline for everything and named everyone I spoke with at Aetna. If they approved me only to shut me up, I’ll take it.

This from getting initial “Sorry you are denied come pick up your paperwork”. I found out my advocate didn’t know how to file and appeal and that’s why she told me that.

Congrats!!! I'm so excited for you! Glad you didn't give up and fought then!