ins exclusion - ThinnerTimes

raquel · 04-09-2007, 10:43 PM

After going through a 3 month diet and psych ordeal my case was sent to the ins lady at vandy and she tells me that it is a direct exclusion with my hubbys work. I know your saying why don't I know this already. Well I have called and been on the aetna web site no one said exclusion. I have been crying all night. So many things I didn't do cause I didn't want to get my hopes up. Last week after my last visit with the nut she told me not to worry I had done everything aetna needed. So I buy some protein, vitamins, calcium, I've started to write down recipes and gather menu ideas. All for nothing.

The part that makes me mad 1: all the things that ins has already paid for (for no reason)
2: my hubby works for HCA Southern Hills Medical Center in Nashville. Just about everyone of their employees would agree that they see many problems with the mo, mo is a disease, surgery drastically improves these medical issues. But they don't allow their employees and their families to get the surgery they need to get better. Maybe HCA thinks that as long as I stay mo I will need to go to the drs and hospital for this or that and then they will get more $

This Sucks

LisaM · 04-10-2007, 04:04 AM

I wish I had comforting words for you, dear, I don't. I can only imagine how devastating this news is for you...my heart goes out to you.

mauldinmama · 04-10-2007, 05:26 AM

I am so so sorry...I know you are heart broken...I wish there was something I could do or say to make it better. I hope you can find a way to make it happen!

hummingbird5953 · 04-10-2007, 05:33 AM

Raquel,
Have you checked into any legislation that your state may have in regard to bariatric surgery?
I ask because I live in Maryland and, here, there is a mandate saying that even if your insurance company excludes bariatric surgery, they must pay for it if:
1) the insurance company is based in MD
2) the employer is based in MD
3) the employer employs at least 50 employees
4) you meet NIH criteria for surgery (i.e. 35 BMI + 2 co-morbidities or 40 BMI)
I realize that you don't live here but TN may have similar legislation. Start by checking with your bariatric surgeon's office. Mine told me about the legislation and they were prepared to help me seek approval via the state legislation because my old insurance company had a specific exclusion regarding bariatric surgery.
Don't give up yet! That's what the insurance companies want us to do...hear 1 "no", take it as gospel, and give up so they don't have to pay.
Good luck!!!!!!

JenBear7 · 04-10-2007, 05:37 AM

Dont give up! There are other insurance companies out there.. even if you have to switch to something you have to purchase on your own, and pay more for... its still a huge savings for the surgery... there is always a way, when the will is great enough! It had to be so devistating. I think this is why the surgeons around here all insist you call your insurance company on the phone and "make sure" YOU are covered for it, before they take you as a patient..

Keep at it girl! Stick with the board for support.. Nothing is impossible!

LoriAnn925 · 04-10-2007, 06:28 AM

Raquel, When I first started looking into WLS the insurance we were on (Aetna) had a direct exclusion as well. The good thing about getting insurance thru your or your husband's work is that open season is just a few short months away, and you have the possibility to change. You just have to research which companies and/or coverage will include the surgery. I researched all the companies and levels of coverage to see which one covered the surgery before we changed our beneifts. Don't give up, While you're waiting for open season, make sure you've got all your bases covered. Most insurance companies require a 6 month physician directed diet. Make monthly appointments with your physician and get that part out of the way, so that when you change insurance you don't have to wait again. Make sure your physician is documenting the right things in their notes: i.e. weight, what you disucssed: eating modifications, exercise, etc. It all has to be in there. Make good use of this time, and you will be better off in the long run. Good Luck!

raquel · 04-10-2007, 08:14 AM

Question??? how do I know that the same thing would be required next year that was required this year? this year there was an exclusion with aetna but there might not be next year. if I do a 6 mth dr supervised diet now then next year there might not even be an ins that offeres bariatric or they may requier the 6 mths to be while on that particular ins. right? But then again they do go back a couple years into our records right. So 6 mths now would be a plus. Cause I will always want this surgery that won't change.

JenBear7 · 04-10-2007, 08:20 AM

Keep going on the diet! Keep weighing in with your pcp.. keep doing everything you know isnt going to change! You know they are always going to require a diet.. you know they are always going to require documentation... you will be READY when the time comes... You can go to support groups prior also.. I hope it works out for yoU! AND SOON!

Baron Patrick · 04-10-2007, 08:38 AM

In the beginning, when I started out investigating wls, I was told by "THEM" (my reference to my insurance company) that wls is specifically excluded. However, by digging deeper, I found that the exclusion does not apply IF I have a BMI of over 40 with no co-morbidities, and IF my BMI is under 30 but over 25 with co-morbities. There are many "conditions" "THEM" love to put on wls. What's frustrating is "THEM" won't come right out and tell you these things, you have to dig and find out yourself. Be persistant!

You need to ask SPECIFIC questions. If you ask "do you cover wls?", then of course they will say no. If you ask "THEM" "Do you cover gastric bypass / LapBand." You may get a different answer. Better yet, ask "THEM" what their requirements are for wls.

Also, be absolutely sure of the requirements by "THEM". The one thing that trips up the majority of us is a "6 month medically supervised diet." This is required by virtually all instuance companies. I'm still trying to figure out why they want this other than as a stalling tactic hoping you will give up. Be aware they may not accept Jenny Craig, Weight Watchers, or other weight loss organizations.

Never take "NO" for an answer.

I wish you the best of luck - and Never Quit!

raquel · 04-10-2007, 08:42 AM

Well I called aetna my self (again) and asked if gastric bypass was covered and she said yes and went on to tell me the amt I will pay at the hospital and so on. Well I explained that tthe dr office said it was an exclusion. She had no idea what she was talking about and talked to someone else and came back on the line and said no bariatric surgeries were not covered. I said I went through this in January and it was covered, went through 4 months of stuff and now you tell me its an exclusion. Why did you pay for all this stuff so far? She said I had a refferal which is all they require. I say "if i got a referal to a vet would you cover that? or a prostate dr? wouldn't you notice that it wasn't something that should be covered and let me know?" no answer so I told them to get it together and hung up.

I am crying and telling my mother everything and she says " well you have been eating better and you don't drink cokes anymore couldn't you just do it on your own?" As she sets there smoking her cigerettes and moaning with her aches and pains that she only sees a 75 year old country dr about. I say to her isn't that the pot calling the kettel black? I thought you understood its not like I'm gonna sit around eating and go back on cokes. She says good go to the barn and get that old stationary bike and use it. My sister has lost some weight and I am proud of her but don't compare me to her. She has lost 20lbs since oct. she is now a size 16. I feel like I'm in a competition.

Needless to say I am frustrated and depressed. I saw a psycho psychiatrist for nothing and all of this $ for nothing. The only thing good is that I have had goals for the first time in a long time and I have got to know some great people here.

Hey, does anyone think the local health media news (whatever...not thinking straight) would think its interesting or see the irony in the fact that the largest healthcare system in the country has a direct exclusion for bariatric surgery?