Guest guest Posted April 10, 2001 Report Share Posted April 10, 2001 Lee, Actually Aetna is not looking at it as a cosmetic surgery. At least the people I talk to. They tell me that I need this surgery. I for one appreciate that. The automatic discrimination is not of people as much as the surgery itself. For instance, someone might say it is healthy to drink arsenic. I am sure the insurance company would disagree with this. I would too. All the insurance company is waiting for is proof that this surgery is not unhealthy and is a good choice for WLS. After all the info I sent them as well as others and their own checking, I think that they are coming to that decision. Anything that would cut down their cost and save them money is a good thing for them. But if they agreed to a surgey that ended up causing more problems or even death, they could be liable. I can see their side too. This surgery is a good thing. hat is why I opted for it. I think they see that now. Now we just have to wait for their procedures of approving the surgery for everyone. I DO think that will happen. It already is on a case by case basis. It just takes a good rep. to help push it through. I am not affiliated with Aetna except that I have been with them for 23 years. They have been very good to me and my family over that time. I really have no desire to go anywhere else. But during that time I have learned that anything is possible with them and just one person can get policies changed if gone about the right way. I have helped to influence change with a few of them at Aetna. --- surfdog1156@... wrote: > Well , it seems like you have a lot of sense. > informing instead of pushing truly would be very > helpful. > I do not like the automatic discrimination against > these surgeries. I know that they look at it as > cosmetic surgery, and of course it is not. > It is both a healthful surgery and necessary > surgery. > Thanks for responding. > Lee H. > duodenalswitch wrote: > > > > Lee, > > > > I think I am in a pretty good position to respond > to > > this one. I too have Aetna (PPO). Most everyone > here > > knows that I have been working with them for about > 10 > > months too get this surgery approved for myself. I > > started by sending my case worker at Aetna ALL the > > research information I had collected for months. > Then > > I also gave ger sites on the web to look up the > > information herself. 's site was a big > help. > > > > I knew ahead of time that Aetna does not cover > this > > procedure. They state that and have stuck to it. > > HOWEVER, After sending the information to my > worker > > and asking her to look at the information > > (Informally), she said she would. I was months > away > > from asking formally for the proceedure. She > looked it > > over and liked what she saw. > > > > She passed it on to her doctor (boss) and asked > him to > > look at it (informally). He did and liked it as > > well. To make a long story short, My rep called me > one > > day and said that I was unoffically denied. Two > days > > later she called back and told me she could not > > believe it. She recieved a note from corporate > stating > > that this surgery was is not approved in the > policy > > BUT, they would approve it for me. And, look into > the > > DS as to changing their policy to include it in > the > > future. > > > > I know that many have been turned down and those > in > > the denial process are still being denied. But > > everyone I have talked to that has Aetna, and have > > asked for this since I started has been approved. > Ask > > Jodie. She just has the DS and Aetna approved her. > She > > applied after I went through the course. > > > > Now I am not saying that everyone will be > approved. I > > can't. But I do know that a lot more have been and > > that they are looking at changing their policy. I > have > > yet to have my DS as I set my own date to fitmy > > schedule. I am scheduled for May 10th, 2001. And I > > have been approved by Aetna for months now. > > > > Hope your journey goes well. I know Becki is > > interested as well as others. All I can say is > don't > > give up. It is not a fight just a plan of action. > > > > If I can be of any help, > > > > > > > > > > > > > > > > --- surfdog1156@... wrote: > > > Thank you AJ for responding. I dont really know > what > > > approach to use in > > > finding the answer here. I have looked high and > low > > > and come up with nothing > > > every time. I was hoping someone had gone before > me > > > and found the answers > > > somewhere. > > > I cant beleive that Aetna is turning down 5 or 6 > of > > > the WLS. I just cant > > > beleive all of the prejudice against Fat People. > We > > > are conintually put down > > > and downright ignored. > > > This is a sin and has got to stop. > > > I see a huge stream of people continuing to > demand > > > WLS for them and one fo > > > these days they all will see that this is not > going > > > away...it is for real. > > > Sincerely, > > > Lee H. > > > > > > << > > > I dont think you can convert a RNY because the > > > whole point of the DS is to > > > save that one part and when you have the RNY it > > > changes your anatomy. I > > > could be wrong but I think its doubtful. > > > > > > Mexico I'm unfamiliar with. There is one in > Spain > > > that does it for around > > > 11,000 US dollars. I know one gal that had the > > > adjustable gastric band done > > > and she loves it. I know for me that would > never > > > work. > > > > > > AJ > > > > > > duodenalswitch wrote: > > > > > > > > Yes , I went to the Aetna site and also found > > > that they are saying they > > > dont > > > > approve DS or BPD surgery. Oh no now what? > > > > > > > > OK Question: Can a RNY be converted into a DS > or > > > BPD/DS surgery? > > > > If some of us have to go that way , the way > of > > > the RNY by forcing it on us > > > > then can we later convert it into what we > wanted > > > in the beginning? > > > > > > > > Also, Is there any MEXICO DRs that do the DS > > > surgery? Does anybody know? > > > > > > > > Thanks so much, > > > > Lee H. > > > > > > > > > > > > >> > > > > > > > > > ---------------------------------------------------------------------- > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 10, 2001 Report Share Posted April 10, 2001 In a message dated 4/10/01 8:18:02 PM Eastern Daylight Time, ib_johnm@... writes: << After all the info I sent them as well as others and their own checking, I think that they are coming to that decision >> One can only hope and pray. Thanks , Lee H. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 10, 2001 Report Share Posted April 10, 2001 Hi Lee. et. al.- I too, read the DS exclusion on Aetna's website. I thought I was doomed. But then I read on this list that Jodi was approved by Aetna. There was also a brief discussion here that speculated that maybe they were getting ready to overturn their exclusion policy. Nevertheless, I went to my consult with Dr. Pomp at Mt. Sinai loaded with all sorts of goodies (amunition) to help them make my case. I have had no personal contact with anyone at Aetna regarding my surgery. As it turns out, Dr. Pomp and staff were pretty confident that they would ultimately win approval for my DS - based on my indiviual circumstances. That seems to be where Aetna is at right now - approval on a case by case basis (most notibly, I have read that the DS is considered a more effective WLS for those with higher BMI's, so maybe Aetna looks for that as a qualifier...). Understand however, that Dr. Pomp's office has not yet applied for my surgery. We are waiting until they get the results of my endoscopy, which I am having in two days. Until then I remain cautiously optimistic - based on their confidence - with all appendages triple crossed. But there is no denying that with these other approvals, a presidence is being set. from Philly BMI 63, age 39 Aetna USHC, HMO - doc thinks they will pay! Open DS w/ Dr. Pomp, 9am on Wed., June 20, 2001 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 10, 2001 Report Share Posted April 10, 2001 Hi Lee. et. al.- I too, read the DS exclusion on Aetna's website. I thought I was doomed. But then I read on this list that Jodi was approved by Aetna. There was also a brief discussion here that speculated that maybe they were getting ready to overturn their exclusion policy. Nevertheless, I went to my consult with Dr. Pomp at Mt. Sinai loaded with all sorts of goodies (amunition) to help them make my case. I have had no personal contact with anyone at Aetna regarding my surgery. As it turns out, Dr. Pomp and staff were pretty confident that they would ultimately win approval for my DS - based on my indiviual circumstances. That seems to be where Aetna is at right now - approval on a case by case basis (most notibly, I have read that the DS is considered a more effective WLS for those with higher BMI's, so maybe Aetna looks for that as a qualifier...). Understand however, that Dr. Pomp's office has not yet applied for my surgery. We are waiting until they get the results of my endoscopy, which I am having in two days. Until then I remain cautiously optimistic - based on their confidence - with all appendages triple crossed. But there is no denying that with these other approvals, a presidence is being set. from Philly BMI 63, age 39 Aetna USHC, HMO - doc thinks they will pay! Open DS w/ Dr. Pomp, 9am on Wed., June 20, 2001 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 10, 2001 Report Share Posted April 10, 2001 , Good comment and great observation. I can tell you that I was approved with a BMI of 43+. Not real high. However, I do have a medium - bad case of asthma, high blood pressure as well as a few more less notable comorbidities. So I do not know if the BMI is a factor or not. I also know that by sending in my info. personally months before I offically requested the DS that they had time to unoffically look at it and that I knew three weeks before I requested the surgery that I was unoffically approved. Once it was requested they told me in two days I was offically approved Hope it goes well with you. --- mibrica mibrica@...> wrote: > Hi Lee. et. al.- > > I too, read the DS exclusion on Aetna's website. I > thought I was doomed. > But then I read on this list that Jodi was approved > by Aetna. There was > also a brief discussion here that speculated that > maybe they were getting > ready to overturn their exclusion policy. > Nevertheless, I went to my > consult with Dr. Pomp at Mt. Sinai loaded with all > sorts of goodies > (amunition) to help them make my case. I have had > no personal contact with > anyone at Aetna regarding my surgery. As it turns > out, Dr. Pomp and staff > were pretty confident that they would ultimately win > approval for my DS - > based on my indiviual circumstances. That seems to > be where Aetna is at > right now - approval on a case by case basis (most > notibly, I have read that > the DS is considered a more effective WLS for those > with higher BMI's, so > maybe Aetna looks for that as a qualifier...). > Understand however, that Dr. > Pomp's office has not yet applied for my surgery. > We are waiting until they > get the results of my endoscopy, which I am having > in two days. Until then > I remain cautiously optimistic - based on their > confidence - with all > appendages triple crossed. But there is no denying > that with these other > approvals, a presidence is being set. > > from Philly > BMI 63, age 39 > Aetna USHC, HMO - doc thinks they will pay! > Open DS w/ Dr. Pomp, 9am on Wed., June 20, 2001 > > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 10, 2001 Report Share Posted April 10, 2001 Lee, If you have a PPO it doe not matter what stae you are in. I had to go through the same process with my wife and her heart condition. We went to Houston for the procedure, twice. They paid the same as if we were here at home. --- surfdog1156@... wrote: > GREAT MICHELLE!!! > Let us know how it all went in a week or so. I also > see that you are not > living in NY. How does Aetna handle out of state > surgeries? It sounds risky > just by way of being a non state resident. > I hope I am wrong. > Good Luck > Lee H. > > In a message dated 4/10/01 9:42:57 PM Eastern > Daylight Time, > mibrica@... writes: > > << Understand however, that Dr. > Pomp's office has not yet applied for my surgery. > We are waiting until they > get the results of my endoscopy, which I am having > in two days. Until then > I remain cautiously optimistic - based on their > confidence - with all > appendages triple crossed. But there is no denying > that with these other > approvals, a presidence is being set. > > from Philly >> > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 10, 2001 Report Share Posted April 10, 2001 Lee, I am optimistic. But then I guess you can tell that from my posts. I have a good poem I can share about choices one makes in life if you are interested. I think I tend to lean toward believing it. --- surfdog1156@... wrote: > In a message dated 4/10/01 8:18:02 PM Eastern > Daylight Time, > ib_johnm@... writes: > > << After all the info I sent them as well as others > and their own checking, I think that they are > coming > to that decision >> > > One can only hope and pray. > Thanks , > Lee H. > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 10, 2001 Report Share Posted April 10, 2001 Lee, I am optimistic. But then I guess you can tell that from my posts. I have a good poem I can share about choices one makes in life if you are interested. I think I tend to lean toward believing it. --- surfdog1156@... wrote: > In a message dated 4/10/01 8:18:02 PM Eastern > Daylight Time, > ib_johnm@... writes: > > << After all the info I sent them as well as others > and their own checking, I think that they are > coming > to that decision >> > > One can only hope and pray. > Thanks , > Lee H. > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 10, 2001 Report Share Posted April 10, 2001 Lee, I am optimistic. But then I guess you can tell that from my posts. I have a good poem I can share about choices one makes in life if you are interested. I think I tend to lean toward believing it. --- surfdog1156@... wrote: > In a message dated 4/10/01 8:18:02 PM Eastern > Daylight Time, > ib_johnm@... writes: > > << After all the info I sent them as well as others > and their own checking, I think that they are > coming > to that decision >> > > One can only hope and pray. > Thanks , > Lee H. > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 11, 2001 Report Share Posted April 11, 2001 In a message dated 4/11/01 12:57:31 AM Eastern Daylight Time, ib_johnm@... writes: << I have a good poem I can share about choices one makes in life if you are interested. I think I tend to lean toward believing it. >> Anything that Helps is appreciated here. Please do send! Lee Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 11, 2001 Report Share Posted April 11, 2001 In a message dated 4/11/01 12:57:31 AM Eastern Daylight Time, ib_johnm@... writes: << I have a good poem I can share about choices one makes in life if you are interested. I think I tend to lean toward believing it. >> Anything that Helps is appreciated here. Please do send! Lee Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 11, 2001 Report Share Posted April 11, 2001 In a message dated 4/11/01 12:57:31 AM Eastern Daylight Time, ib_johnm@... writes: << I have a good poem I can share about choices one makes in life if you are interested. I think I tend to lean toward believing it. >> Anything that Helps is appreciated here. Please do send! Lee Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 11, 2001 Report Share Posted April 11, 2001 I was self-pay while I waited approval from Aetna. I had the surgery without approval from insurance. What happened was they did not approve the Ds PART of the surgery. They did however approve the gastric bypass. So, they paid for everything except part of my surgeons fee. Which ended up being with Rabkin the $3,000 fee he charges and about $5,000. So, I ended up paying about $8,000 out of the surgeons $12,000 cost. Almost all my other charges were covered except of course for the deductibles! I was pretty happy with the outcome. I was worried I would have to pay the hospital fee of $33,000. Well, that is my Aetna update. I was confused for the longest time because they originally denied me and after the appeal they did cover the above..so hang in there Aetna people! Brigid Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 20, 2001 Report Share Posted April 20, 2001 I've posted before of my Aetna " approval " . They approved me of the bypass with OUT the duodenal switch. Which turns out to be almost all of the charges. I self payed first and they in turn reimbursed me for services covered. THe only thing they didn't cover was the surgeons fees which ended up being about $6,000 plus Rabkins $3,000 fee. I have Aetno open choice PPO. I hope this helps! Brigid switched Nov 14, Rabkin Pre-op 276 April 195 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 20, 2001 Report Share Posted April 20, 2001 I've posted before of my Aetna " approval " . They approved me of the bypass with OUT the duodenal switch. Which turns out to be almost all of the charges. I self payed first and they in turn reimbursed me for services covered. THe only thing they didn't cover was the surgeons fees which ended up being about $6,000 plus Rabkins $3,000 fee. I have Aetno open choice PPO. I hope this helps! Brigid switched Nov 14, Rabkin Pre-op 276 April 195 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 20, 2001 Report Share Posted April 20, 2001 I've posted before of my Aetna " approval " . They approved me of the bypass with OUT the duodenal switch. Which turns out to be almost all of the charges. I self payed first and they in turn reimbursed me for services covered. THe only thing they didn't cover was the surgeons fees which ended up being about $6,000 plus Rabkins $3,000 fee. I have Aetno open choice PPO. I hope this helps! Brigid switched Nov 14, Rabkin Pre-op 276 April 195 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 12, 2003 Report Share Posted September 12, 2003 Yes, I ran across this. I also have Aetna and they just changed to the 6 month diet thing in January of this year. But they did not tell me it had to be an approved diet. They just said 6 month dr supervised. Guess I'm calling them today. I was also turned down by my second insurance, because my primary, Aetna turned me down. And TriCare approves everyone. I know it doesn't help, but I just wanted to let you know this is how it is. The doctors don't fight it. Can't, the insurance company will not approve without the diet. But all his evaluations should be good after the 6 months. I think it's only after a year that you have to have them redone. Good luck. My surgeon would not appeal...so I'm waiting still... Quote Link to comment Share on other sites More sharing options...
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