I'm so disillusioned... - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

jmh324 · 06-29-2009, 07:24 PM

After 30 years of battling my weight I finally made the difficult decision to consult with a bariatric surgeon in March. My BMI is 40-41 and I just recently was diagnosed with sleep apnea. My insurance is Aetna and I went through the 3 month multidisciplinary program and did everything I was supposed to. My surgery was scheduled for today. Two weeks ago my doctor's office supposedly submitted everything but it took until last Wednesday for Aetna to confirm there was even a case pending. Friday morning they denied me based on the fact that although my BMI was 40 in 2007, it did drop down to 36 for a couple of months in 2008 when I was on a SEVERELY restricted anti-candida diet. They are saying I didn't have sleep apnea then so that disqualifies me. My doctor's point is that I just had not been diagnosed. In my doctor's notes from 2007 it very clearly states that I was having sleeping problems, but no one thought to test me for apnea. Anyway, since Friday morning they've been trying to set up a peer-to-peer phone call with Aetna. I'm not sure what the hold up is but every time I call they say they are waiting for the insurance guy to call back. My doctor's office said if they get the approval via the peer-to-peer (they intend to fight for me tooth and nail) they can reschedule me for Wednesday, but today was another wasted day. I'm not going to work tomorrow because I'm so stressed and do not feel like dealing with the "have you heard yet" questions. I am so upset and so disapppointed right now I just don't want to see or talk to anyone.

Crimson Kittie · 06-30-2009, 01:50 PM

Don't give up ... lots of people are denied on the first go round.

(((((hugs))))) Things may still work out .. just keep working with your doctor

JustJoy · 06-30-2009, 01:56 PM

Quote:

Originally Posted by jmh324

After 30 years of battling my weight I finally made the difficult decision to consult with a bariatric surgeon in March. My BMI is 40-41 and I just recently was diagnosed with sleep apnea. My insurance is Aetna and I went through the 3 month multidisciplinary program and did everything I was supposed to. My surgery was scheduled for today. Two weeks ago my doctor's office supposedly submitted everything but it took until last Wednesday for Aetna to confirm there was even a case pending. Friday morning they denied me based on the fact that although my BMI was 40 in 2007, it did drop down to 36 for a couple of months in 2008 when I was on a SEVERELY restricted anti-candida diet. They are saying I didn't have sleep apnea then so that disqualifies me. My doctor's point is that I just had not been diagnosed. In my doctor's notes from 2007 it very clearly states that I was having sleeping problems, but no one thought to test me for apnea. Anyway, since Friday morning they've been trying to set up a peer-to-peer phone call with Aetna. I'm not sure what the hold up is but every time I call they say they are waiting for the insurance guy to call back. My doctor's office said if they get the approval via the peer-to-peer (they intend to fight for me tooth and nail) they can reschedule me for Wednesday, but today was another wasted day. I'm not going to work tomorrow because I'm so stressed and do not feel like dealing with the "have you heard yet" questions. I am so upset and so disapppointed right now I just don't want to see or talk to anyone.

Don't give up yet. Your doctor's office is willing to fight hard for you, you need to be willing to fight for yourself. Appeal, appeal, appeal.

I have a very good possibility of being denied when we file for approval next month. I may have to do another three months of doctor supervised dieting due to one of my insurance companies changing the way they interpret the policy. I'm willing to sue for the coverage if I have to. It took me too long to get to where I'm at now, I'll be darned if a few bureaucrats are going to stop me.

Don't let them stop you or suck the fight out of you. I understand feeling defeated right now. But don't let it consume you okay?

Take care of you.

Beth in Texas · 06-30-2009, 02:55 PM

I have my fingers crossed for you--I'm also with Aetna, and you may as well call us pioneers of a sort.

I'm told that Aetna just began coverage for Bariatric patients in April of this year--don't know if they meant Texas, or the company I work for (Dell) but, I have a feeling that we might be best to anticipate failure at first and be prevalent in hitting them back right away with whatever the insurance company asks for.

I believe your doctors are truly going to push for you. And you know we are!

Keep your chin up!

--Beth

jmh324 · 06-30-2009, 06:56 PM

Thanks everyone. I took off work today because I was so stressed and hoping to hear one way or another. Apparently the peer-to-peer happened yesterday late afternoon, now I'm just waiting on a decision. I'm not giving up without a fight, and from the sound of it, neither is my doctor's office. I'll keep you posted. Thanks!

jmh324 · 07-05-2009, 08:19 AM

Well, I was denied again, this time from the peer-to-peer. Now we have to appeal....

Helena · 07-05-2009, 08:50 AM

Know what really pisses me off is the company we work for pay the insurance premiums and the insurance company decides your life...You can't tell me the insurance companies aren't making a bundle of money deciding our future health....What a racquet....

jmh324 · 08-01-2009, 05:08 PM

I have not received the letter yet, but when I called Aetna on Thursday to check the status of my appeal she told me they overturned the previous denial and I have been approved, and that the letter was sent out last Tuesday. I immediately called my insurance coordinator at my surgeon's office and we both did a happy dance over the phone. I am now scheduled for surgery on August 19th, 3 days after my dad's 80th birthday celebration. I've taken the time off work AGAIN, and now I just have to be 100% sure I want LGB versus the Lapband. I've been approved for Gastric Bypass. My only hesitations are these- how much gas/bad breath do y'all really have? And for those of you that are past the year mark, can you eat almost anything? Can you eat any sugar/fat or is that something your body really can't tolerate? Just curious to see what percentage experience dumping, etc? There's a small part of me that thinks the lapband is the safer, better surgery, but truthfully if I am going to have surgery I want the best odds of success. Any opinions? It may all be moot anyway, because I have had 3 prior abdominal surgeries, so once they are in there, there is a chance I may have too much scar tissue for him to do the bypass. They asked what I wanted at that point and I said lapband, don't put me through surgery and wake me up to tell me I have nothing. LOL

Vikkator · 08-01-2009, 05:23 PM

Congrats on getting your date. I wouldn't worry so much about the gas and bad breath. I personally didn't have many problems with gas (unless I eat too many beans), but that's not to say you won't. Everyone is different. As far as the bad breath, that can be remedied with mouthwash or breath mints.

I'm not past the year mark, but getting close. I can't eat much of anything that has fat or sugar, but I can pretty much eat anything else as long as I don't overdo it. The best thing I've found about having had this surgery is that I don't care about food, so giving that stuff up isn't a big deal. What's been hard for me is finding something that I want to eat and when I do, it's not much.

This is how I wanted to be, though. I wanted to eat like a thin person eats. I've lost close to 100 pounds and would never have been able to lose this much any other way. It has changed my life. I've found that there are many things in life that are more satisfying in food, like fitting into a size 10, being able to walk a mile, playing frisbee, climbing stairs without huffing and puffing...am I getting through to you?

Only YOU can decide how you want to live your life. I wish you all the best, my dear.

Beth in Texas · 08-01-2009, 05:32 PM

Congratulations!!! That's awesome news!