Aetna

**Alexandra** · 07-22-2003, 08:50 PM

Aetna still considers the LAP-BAND® "investigational/experimental" and excludes it completely on a company level. I have never yet heard of any cases where Aetna paid of its own accord, so unless or until Aetna changes its policy on the band being investigational the best bet is to see if you have an external appeal provision in your state. I did, and I won! Here's how it went:

The State of New Jersey, like many other states, provides for a third-party review of insurance carriers' decisions. That means there might be a law in your state that provides you with the right of EXTERNAL review if you have exhausted your company's appeal process and lost.

In my case, I took my Aetna denial through the third-party process, and my case was referred to an INDEPENDENT reviewer in accordance with the state's mandate. The third-party reviewer agreed with me that the band should not be considered investigational and that IN MY CASE it was a medically necessary procedure.

Now, I knew from the start that Aetna had a policy against covering the band, and I also knew that I couldn't switch insurance carriers until my company's next open-enrollment period almost a year away. So I decided to get started anyway investigating weight-loss surgery. The pretests and qualification criteria are the same for all types of bariatric surgery, so the carrier may very well cover what your primary care doctor refers you for in the early stages. Even if you have an exclusion for weight-loss treatment, perhaps some of the visits and/or tests could be covered simply as diagnostic procedures. Aetna covered the office visits (except for the psych eval, because the person I had to go to was out of network and I have an HMO), blood tests, nutritionist visit, and so on.

All of this took more than three months to accomplish. Then the cycle of request, denial, appeal, denial, stage 2 appeal, and final denial took another three months. Then I took my request to the state and waited *another* two months before the decision was finally made. Now it's almost a year after I started and if I hadn't won my appeal I would be switching carriers right about now with all my prequalification testing long behind me. I wouldn't have to start all over again with another carrier.

My point is that even if you know or think your carrier won't cover it, start anyway and proceed as though you are considering ANY type of weight-loss surgery. You'll be glad you got started, because it takes time to amass the tests and histories that every carrier needs to evaluate candidates for WLS. A year from now, Aetna and other behind-the-times carriers may very well have changed their tunes completely and you'll be that far ahead of the game.

Ginger2120 · 07-23-2003, 09:42 AM

I did take your advice about the state department of insurance, and I am finalizing my paperwork to send to them today. I also received my final denial letter from Aetna, and the good news is that in there letter, they totally contradicted themselves! There was a section that said under no circumstances was the Lap-Band® approved, but in another spot on the same letter they said that it was approved in individual cases where the patient could not have the gastric bypass. So I'm including that letter with my other information for the state. I'm very optomistic that I will be approved and banded before Christmas :banana

**Alexandra** · 07-23-2003, 05:25 PM

Quote:

Originally posted by Ginger2120
There was a section that said under no circumstances was the Lap-Band® approved, but in another spot on the same letter they said that it was approved in individual cases where the patient could not have the gastric bypass.

Wow! That's the first chink in the armor I've ever heard of--that's wonderful!

I think there are significant reasons one would choose banding over bypass, and mentioned a couple in my appeal letter. I particularly cited my prior experience with very rapid weight loss (Optifast, blech--75 lbs in 12 weeks) and described the emotional and physical upheaval it caused. I wonder if that would have counted as being "unable" to have the bypass?

Good luck, and please keep us posted!!

Ginger2120 · 07-25-2003, 08:41 AM

I guess what makes me so optomistic is that in August of 2002 I went to the Bariatric Treatment to have a gastric bypass. Aetna approved me for that in less than a month! What the surgeons found out when they opened me up was that I have an abnormal rotation (basically my small intestine is backwards) in my small intestine so the part they need to bypass wasn't long enough, so they closed me back up and said sorry, there's nothing we can do for you.

So when I get this last letter from Aetna with there exception written on there I got really excited because I am a MAJOR exception to the rule! Only one out of like 4 million people have backwards intestines.

I'll keep you posted on what happens and hopefully be posting a surgery date within the next few months.

**Alexandra** · 07-25-2003, 11:57 AM

Backwards intestines? Wow. That sure sounds encouraging, Ginger, you alien. :D

All the best to you and I can't wait to hear your good news!

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