Aloha55

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About Aloha55

  • Rank
    Newbie

Profile Information

  • Gender
    Female
  • Location
    California

Information

  • Hospital
    John Muir
  • Height (ft-in)
    5-00
  • Start Weight
    211
  • Current Weight
    210
  • Goal Weight
    140
  • Body Mass Index (BMI)
    41.2
  • Surgery Type
    Vertical Sleeve
  1. APPEALS, APPEALS, APPEALS .....

    I'm aware this is an old forum, but I'm just like many out there searching for answers & updates, so here I am. I happened to finally find this one (maybe old, but was helpful). I wanted to share my experience. My journey started back in March of this year to make a change. I had suddenly became way overweight and unsure as to why until now after so much research. In 2010, I weighed 150lbs and I was happy even if I was still 30lbs overweight. Then all of sudden I experienced so much pain during my menstrual periods and having cysts develop in my tubes & ovaries. October 2011, I weighed in at 160lbs and gaining. No clue as to why. Fast forward, I was diagnosed with Stage 4 Endometriosis. I am now 210lbs. The combination of medications and my disease caused my weight gain. I started doing my research as to what was required to be qualified for WLS. I already had 1 of the requirements for Aetna-I had a BMI over 40 (41.2)-I started seeing my dietitian for consults as stated on preoperative regimen of Aetna's policy; 3 months and no net weight gain during the program. Easy?! Yup, it was. Or I thought it was easy enough to get an approval. I weighed in starting at 211lbs in June (the beginning of the program). I seen my PCP, my surgeon and my dietitian every month and weighed in each time. I'm a nursing student so the only available time I can go in is late afternoon. I weighed in around 2:30pm-430pm at each appointment and each time the scale went up. Why? Because I was weighed in with all my clothes & shoes. Aetna denied me twice. The first denial (July 27th) was based on the 90 days consultation with the dietitian. Ok cool, I had only 70 days out of 90 days. August 23rd, I weighed in at my surgeon's office at 218lbs @ 2:30pm. Went to see my PCP at 4:30pm weighed in 214lbs with my undergarments on and a paper gown. I knew it was because of the undigested food still in my system. Notes submitted to Aetna. I already knew it was going to be bad. 2nd denial (September 9th) based on a net gain of 7lbs during the program! GREAT! I knew it. As soon as I got off the phone with the insurance, I called my PCP and requested a weight check appointment at the earliest time they had available in the morning because the most accurate reading is in the morning after everything you ate has digested in your sleep. I came in at 7:45am on September 16th and weighed in at 210.8lbs!! A real big difference. I wrote a letter addressing the inaccuracies on weighing me in during the late afternoons and fully clothed with shoes. I wrote a letter for the second level appeal & so did my doctor's office. The second level appeal letters were sent to Aetna on September 19th. I called everyday...I mean everyday and so did my doctor's office. I called on September 29th and Aetna reversed their decision and approved my surgery. So, thanks to NUTTUMOONBRIDES story I felt confident they were going to approve it. I hope my story helped you.