gchristine

Can I ask what type of "Aetna" you have? I also have Aetna, and am beginning this whole process, so I am interested. Thanks!

adagirl

I have Aetna Choice POSII (NAP) and am in Arizona. The way I understand it, though, this doesn't mean a whole lot on its own. Someone else's card may say the same thing, but they might have an exclusion for weightloss surgery. The first thing you should do is call or email Aetna Member Services, provide your ID, and ask if there is an exclusion for WLS for YOUR plan. If there is no exclusion, then that means they will cover it as long as you meet Aetna's requirements. These requirements can be found here: Obesity Surgery

If there is no exclusion and you think you can meet the requirements, then that's when you might want to check into more details w/your particular insurance... like what your copay will be, what is the max out of pocket you might be responsible for, how many appeals are allowed under your plan if you are denied, etc. My plan actually allows for three appeals, but I'm not bothering to do any additional appeals since the only thing I am lacking is a high enough BMI in 2007. When you submit weight history, you just pick the highest weight you have documented w/a doctor from each of the two previous years and the current year. My problem is that even my highest weight in 2007 is not high enough. Damn Weight Watchers!!! LOL

One of the other first things I did (once I knew there was no exclusion) is I started to gather all my past medical records. If you've seen a lot of different doctors over the years, this can take awhile to get everything together. Best of luck to you!!!

adagirl

Update... I got the official letter in the mail yesterday that laid out exactly the reason for denial. I hadn't originally planned to do a second level appeal, but decided what have I got to lose... except my sanity of course?!?! Oh, yeah, I've already lost that so may as well. LOL

So, today I sat down and wrote them another two page letter. I only had a few other points to make for my case. I am very doubtful anything will come of this, but the 2nd denial letter said I had to make my 2nd appeal within 60 days or my case would be considered closed. Since 60 days comes before January 1st, I would have to submit everything from the beginning again in January anyway. I wouldn't be able to appeal on top of my existing paperwork. So, I figured I may as well submit a second appeal since there is no reason to 'save' it.

Another thing I though of is what if they just find another reason to deny me in January... then I have to go through the whole appeal process again. I might as well exhaust all my appeals w/this one before I start over.

FatButNotHappy

Hey I just wanted to share this with you and I don't know how true it is so please verify it with Aetna. I was told that if they deny you on appeal the case is closed forever and you cannot try again. That may be after the third appeal though. And, of course it may not even be true. But some dis tell me that.

__________________
Stacie
OH...I was FINALLY APPROVED, baby. Surgery scheduled for 12/7/09

10/02/09 APPROVED
08/06/09 DENIED

5' 3.75" (always said 5'4" until BMI came into play)
242/240/150

Blah Blah Blah Who cares about all that other weigh-in crap that I had listed in my signature before, I was friggin approved!!!

YEEE HAW!!!!

adagirl

Thanks for the heads up on this. I sure hope this is not the case, but I just shot an email off to Aetna Member Services to make sure. I would THINK that you just would not be able to submit again within the same calendar year, BUT as I am now starting to understand about insurance companies, you should never assume anything they do would be logical. Ha!

In any case, either way, its good that I submitted the second appeal then cause on the first appeal denial, it said they would consider the decision 'final' if I did not respond within 60 days. Sooooo, I guess if it really is final forever, it would've been final forever in 60 days anyway. But, if that's really the case, then I need to seek legal council before any external review takes place. For my particular insurance, you have up to 2 appeals and then external review and/or litigation past that. In any case, I'm not gonna let this go. I'm like a dog w/a bone now! Watch out Aetna!!!

Heck, if I really can't get them to pay then I COULD do self-pay. Almost seems worth it sometimes. BUT, the main thing that prevents me from going that route is not so much the known cost of the initial surgery, but not wanting to put my family's savings at risk in case there are complications. The big catch w/any insurance company is if they didn't approve the original surgery, they ain't gonna pay for anything related to it or the fills/followup which can be expensive w/lapband. If I was self-pay and had it completely up to me, though, I'd get the sleeve so no fills.

Aghghghghghghgh, I don't even want to be thinking about this. So frustrating! But, I do appreciate you giving me a heads up that this COULD be a problem. At this point, I really don't need any surprises. Also, thanks for sending me your appeal letter. It helped me come up w/some new ideas for ammunition for my second appeal.

adagirl

So, I sent a message to Aetna Member Services asking all kinds of questions about what happens if my level 2 appeal is denied... mainly, can I resubmit on 1/1/10 (new calendar year).

The message I received back was "We have received your II level appeal and forwarded on to the appropriate department for handling. You will receive a response from us shortly."

First of all, I just sent it at the end of the day yesterday so I really highly doubt they already received it AND their response answers NONE of the questions I asked. Gotta love the canned response, eh! Oh well, so I sent them another message asking again that they answer my original questions. I would call, but I don't trust anything they would tell me on the phone. I want it in writing so if they go back on their word I'll have proof of what they said. Its annoying though to wait a whole day for a response and get a canned one sentence message that doesn't even answer your question.

dswofford

Sorry for your frustration. Keep us updated. I know I am frustrated and I haven't even got everything submitted to the insurance company yet!

__________________
Deborah Swofford
5'2"
Starting/Current/Dr Goal/My Goal
274/265/170/140
Staying in the moment the best I can!

adagirl

OK, now I just remembered that member services sent me a message before that said my plan allows for 3 appeals. The letter I got made it sound like 2, though. Am I losing my mind or are they trying to confuse me?!?! I'm glad I have it all in writing. In any case, so if they do deny this second appeal AND won't allow me to resubmit in January, it looks like I will still have one last appeal left (if they honor what they wrote me in the first message). OK, enough rambling...

By the way, a general tip for anyone dealing w/Aetna and on pins and needles waiting to hear back on stuff. If you log onto the site and then click on 'Contact Us', then 'Member Services', you can write a message from there and hear back within 24 hours. I like this cause everything is documented in writing then. And, I've found that they make most decisions pretty quickly (first decision was made in 5 business days and my appeal was decided in 6 business days). But, if you WAIT for the letter to come in the mail, you will be waiting a whole week longer. So, if you are antsy, you can contact them through the website and find out sooner. Of course, you can call too, but I am so paranoid about having someone tell me something on the phone and not having any proof of it. I've heard so many stories that people call and get told something different depending on who they talk to. Its a mess!

adagirl

Hang in there! Hopefully yours will go smoothly. I've seen A LOT of Aetna approvals happen very quickly, as long as all the criteria is met and the documentation is there. Technically, I don't meet their criteria so I knew I'd be in for a fight.

adagirl

OK, I actually got my question answered this time...

"We understand you have filed a second level appeal of the denial for
your surgery. If the appeal is denied you will not be able to appeal
the denial again.

In the future if you have met the criteria for which the
pre-certification was originally denied, you or your physician may then
submit a new pre-certification request."

That's what I figured and that is fine. It didn't make sense that you would never be able to submit again ever, but I'm also glad to confirm that there is no waiting period between the 'final' decision and being able to re-submit. So, if I need to resubmit in the new year, I'm gonna get all my paperwork ready ahead of time, go in to get weighed on 1/1/10, and have my surgeon's office resubmit it all again.