Okay..here's the deal (hi everyone by the way..this is my 2nd post) I currently have Aetna..and it seems like my surgeon's nurses and everyone is being so negative about this process. At first I needed the 5 years of weight history..I could only find 4 years..I called them and they were quick to say well..it will probably be denied (I remembered I had an ear infection for the missing year and went to the ER so that issue is resolved). Then my mom called them to ask them a few questions and she was told (I was on the phone with her) that if the insurance company denies me for the surgery they do NOT appeal it! THEN just today I called the surgery scheduler and was told that if I do not have a co-morbidity that they will probably deny my request. Even when I told her that the Aetna website says you must have a BMI over 40(which I have had atleast 5 years)..or have 35-40 with a co-morbidity...she was like..yeah but you must have diabetes..or hypertension..(I have neither..my blood pressure reads high at times because I get nervous when I'm at the doctor) I told her that I may have sleep apnea and she said that doesn't really count as a co-morbidity. She also said it really just depends on who is assigned the case. I'm so discouraged about this whole process that I'm about a day from just saying forget it! It's been about a month that I've been trying to get all this and it's like they aren't helping!! Sorry.

Edited February 10, 200917 yr by 2Legit2Quit

Ok, find another surgeon and quickly. It sounds like someone's office staff doesn't want to do their job and you don't want them screwing things up for you with your insurance company. Ask for your file and go somewhere else.

The case manager's at my surgeon's office were friendly and helpful. I had my approval in less than a week. You deserve someone who is willing to put forth an effort. The "we don't file appeals" is a clue that they aren't going to work for you. Good luck!

That is just silly. It sounds like someone who is out of work and needs a job could certainly take that woman's place if she doesn't want to or know how to do her job. I agree with the first responder---find another surgeon. If that would take a lot of time and you want to try to get into that surgeon--then ask to speak to the office manager or head nurse. But--no matter what happens -- do not ----I repeat --- DO NOT (!!!) give up or let this incompetence put you off or slow you down! I'm a bit concerned that these economic times may cause insurance companies to reduce the types or amount of their coverage for some medical proceedures so -- do everything you can to proceed ASAP.

Best Wishes

I agree, pick another surgeon.

I don't think you should give up. I do know, however, that some folks have had to wait up to 6 months and jump through all manner of hoops in order to get insurance to pay. I am scheduled for self pay, but I have still appealed. If they approve before I go in, I will let them pay for it. If not, I will put it on a credit card. In my case, the insurance company would not accept an appeal from the doctor. I had to write the appeal. I can include a statement from my doctor, but only once the appeal process advances another two steps to the in-person appeal.

I do agree that you might consider looking for another doctor, though. You will need to use this office for the aftercare for years to come. If she is difficult, you might be somewhat "married" to a difficult person for a long time. It is harder to find a doc who will care for you if another doc did your surgery. Hang in there. This is tough. If you do choose another doc, I'd write a letter to the one you're leaving and tell him why. I hate to think of a good doc being taken out of the rotation just because he has poor help up front. He might not even know...

Stick with the process and stick with the doc.....but talk to whoever you need to (office manager, the surgeon, etc.) and tell them that their staff is close to costing them a patient. Times are tough and there have been 600,000 people laid off since January 1, 2009. I'm sure the people who count the dollars are not aware of the pissy clerks attitudes. And also, let them have it too, if they are rude and unhelpful, blast em' and give them a piece of your mind.

I agree with what everyone else said, it sounds like there's a pissy person at the surgeon's office who is being lazy. You do not need anything other than an over 40 BMI for two years to get approval from Aetna. You do need to do the six or three month diet, have a psych eval and things like that, but in terms of weight it's just the over 40. I was approved by Aetna in one day with a BMI that ranged from 40-41 over the past two years. Keep trying and good luck!

Plenty of competition for doing this surgery out there. Do some interviews and find someone who is 100% on board with helping you make this life transition. And then let the office manager of this woman know why you switched. Its competitive now...tons of doctors are doing this surgery. There's no reason at ALL for you to feel like they are doing you favors.

AIT>>> I have Aetna too...I am just starting this process, and am scheduled to go to a seminar on 2/19. I researched Aetna's website, and it looks like they only "technicaly" allow Gastric Bypas, with all the stipulations met of course. Can you tell me what type of plan you have? Yes, I'm nosey! :thumbdown: I am paranoid that I will get my hopes up, then get shot down by insurance. We really can't afford to do this out of pocket. I can't wait to start this process, I only hope my insurance allows me to finish it!

By the way, I agree with several others in this thread, go above this pidly office worker you are dealing with, I am sure the higher ups want your business more than she does!

waynes6 I have Aetna Open Access. I just went on Aetna's website and these are the procedures they cover (I bolded underlined the band):

Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures:

Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met.

I had a very easy time getting approved by Aetna, and from what I've heard and read on these boards, if you meet their requirements and take the steps they mandate then you'll be approved.

Good luck!

Whatever you do don't quit. Hang on! Can you select another surgeon?

I've got Aetna HMO. At first I thought they wouldn't approve it, but all I had to do was ask my primary care doc. She had her office person contact my insurance...and they got a referal for me to see the surgeon. Went to do that. As it turns out I do have to document 6 months on a supervised weight loss program. Checked in this month as "month 1". Still haven't gotten the referral for the nutritionist which is supposed to be part of it, but doc's office says it was approved and is still pending. There's got to be someone else you can talk to.

Have you seen this surgeon yet? Do you like him/her? I think you should look for another surgeon, as well as write to the current surgeon with the problematic staff - let them(her/him) know what the process has been like with the front office thus far.

Edited February 11, 200917 yr by ibelieve

I thank you all SO much for your encouragement!!! I could go to another surgeon but I'm almost done here. I've already done everything I needed to do..now it's just sending the stuff to Aetna..and getting the letter of necessity. I figure now I might as well try to finish here. I chose this surgeon because I know atleast 5 people here at work who have went to them and my mom's friend went to them as well and they all had good reviews. I think it's the staff and not the surgeons themselves-they seem really nice. For the "supervised visits" and such..we went to another place so I never actually dealt with the surgeons directly and their staff until now. I just have absolutely no faith that they are going to submit everything that's needed. Everything else has been smooth sailing...I have Aetna Comprehensive Traditional *shrugs* don't know what that is. Again I thank you guys because I truly was ready to quit. Good luck to everyone!!!

Stick with the process and stick with the doc.....but talk to whoever you need to (office manager, the surgeon, etc.) and tell them that their staff is close to costing them a patient. Times are tough and there have been 600,000 people laid off since January 1, 2009. I'm sure the people who count the dollars are not aware of the pissy clerks attitudes. And also, let them have it too, if they are rude and unhelpful, blast em' and give them a piece of your mind.

Your sig says you were approved yesterday! Exciting!!!!!!!:thumbup: