Just starting to explore options...help!!!

leatha_g · 07-20-2004, 12:19 AM

way to go sue!! you beat them with their own BS. lol. love when that happens!

leatha

GeezerSue · 07-20-2004, 12:21 AM

Quote:

Originally posted by leatha_g
way to go sue!! you beat them with their own BS. lol. love when that happens!

leatha

Me, too. And it's easier than making up your own BS...

New Hope · 07-20-2004, 03:37 AM

We used to have BC/BS. You need to ask them to send you a copy of their appeals process. You have to follow this thing to the "t" in order for them to even look at it. ( There is a post on here from someone in the N.E. with BC/BS who was approved in 2 days.) Of course, they all make their own rules.

**Alexandra** · 07-20-2004, 08:07 AM

Following Sue's lead, here is the text of the letter that ultimately won my external appeal of Aetna's denial. This version was originally sent to Aetna, but I just recycled it for the external review board. The arguments remained the same all throughout the process. Note: This is just a sample letter with facts that no longer apply. Anyone considering adapting this letter should look for more recent medical citations to support your case.

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I hereby request a review of the abovereferenced denial of authorization for Laparoscopic Adjustable Gastric Banding (LAGB). The reason given for the denial was: “[LAGB] has not been proven to be a safe and effective procedure.” It is hard to fathom how Aetna can classify the procedure this way, and I hereby request reevaluation of this decision.

Aetna’s own Coverage Policy Bulletin #311, dated November 22, 2002, includes the erroneous statement that “Laparoscopic gastric banding, including laparoscopic-adjustable silicone gastric banding, has not yet been approved by the Food and Drug Administration for treatment of patients with medically severe (morbid) obesity.” In fact, this procedure was approved by the FDA in June of 2001, more than eighteen months ago.

The medical community has long endorsed bariatric surgery as an effective treatment for morbid obesity. Procedures and techniques have evolved over time to be safer while continuing to provide substantially effective treatment. However, there are still significant risks involved with RNY or other invasive bypass surgery, and the relative safety of the LAGB is absolutely undeniable. Please share with me your basis for the statement that it is ”not proven” to be safe.

The long-term goal may be to reduce my excess body weight by 80-90%, but a loss of even 50% of my excess weight would drastically improve my health and nearly eliminate the long-term risks caused by morbid obesity. LAGB patients achieve their weight loss in a more gradual manner than RNY patients, with only a FRACTION of the risk. But achieve it they do, and the evidence is multiplying all the time. There are significant advantages to this procedure over bypass surgery for certain individuals, specifically those like myself who, although suffering from morbid obesity, are in otherwise good health. I have two small children and simply will not take the risks inherent in more drastic surgical procedures.

The fact that the weight loss that will follow the LAGB procedure is more modulated than that following the RNY--but no less permanent--is precisely one of the major reasons I believe it is preferable for me. Indeed, I personally have previously experienced a 75-lb loss in a period of 12 weeks, and can attest to the physical, emotional, and psychological disruption that followed. LAGB will result in precisely the result necessary to greatly improve my health without endangering it--in other words, “effective.”

The surgeon I am working with, Dr. Alexander Abkin of Florham Park, NJ, has carefully evaluated my suitability for surgery. I’ve had a psychological test and nutritional counseling, and he and my other physicians support my very considered conclusion that I am a good candidate for LAGB surgery.

From the journal Obesity Surgery, 12, 380-384, “Laparoscopic Adjustable Gastric Banding at a U.S. Center with up to 3-Year Follow-up”:
Percent excess weight loss averaged 27.2 at 6 months (range 1-68), 38.3 at 1 year (range 10-77), 46.6 at 2 years (range 16-89), and 53.6 at 3 years (range 21-94). Conclusions: In this study up to 3 years, LAGB provided a safe and sustainable weight loss. Significant resolution of serious co-morbidities was common.

From the same issue, in “Laparoscopic Adjustable Esophagogastric Banding: Preliminary Results”:
Conclusions: The technique has a re-educational function, in that patients are induced to chew thoroughly, to introduce small morsels of food and to prolong the mastication time, in order to avoid dysphagia. Laparoscopic adjustable esophagogastric banding gave no problem if well positioned, and promoted new alimentary habits through a dysphagic mechanism, inducing significant excess weight loss.

From Obesity Surgery, 12, 83-92, in “Outcome Predictors in Morbidly Obese Recipients of an Adjustable Gastric Band”:
Conclusions: Lap Band was associated with a good outcome and with a low rate of severe complications. The outcome was more influenced by physiological and technical reasons than by psychological or behavioral factors.

Most other major insurers in the state of New Jersey readily approve this procedure for patients meeting the diagnosis criteria. The few and minor complications that may occur have been decreasing steadily in occurrence as US surgeons gain experience, and the procedure has been used internationally for a decade with no significant incidence of serious complications. Compared to the other bariatric surgery options available, the LAGB is profoundly safer and proven to be effective in achieving the goal of significantly decreasing the health risks associated with morbid obesity. No less important, I’m sure, is that the procedure’s costs are a mere fraction of those related to RNY surgery, particularly since at Morristown Memorial Hospital it is outpatient surgery.

With these facts in mind, I request that Aetna review Dr. Abkin’s request for coverage verification of my LAGB treatment and reverse its earlier decision.

leatha_g · 07-20-2004, 09:25 AM

Very good letter, Alex! I'm sold!

07-20-2004, 09:42 AM

Wow - Again thanks to everyone! This is a great board for support and information.

hagerteresa · 07-20-2004, 11:00 PM

WOW That is an amazing letter Alex. I kind of wish I had chosen to try to fight my insurance company after reading it. How could they have argued? Unfortunately my company wouldn't cover any variety of weight loss surgery so I doubt I would have gotten far. Good luck Brando. Teresa

**Alexandra** · 07-21-2004, 06:39 AM

Teresa, that is exactly the crux of the matter. When we fight our insurance carriers we have to be sure we know EXACTLY what their issue is. If there's an ironclad exclusion against bariatric surgery of any kind, for anyone, in your policy, it'd be very hard to argue against that. The argument I had to make was much easier, since the ONLY reason I was ever given for denial was that "not safe and effective" b.s.

Aetna had never said I wasn't a good candidate, or I didn't meet all their medical criteria, or my policy didn't cover it, or anything of that kind. In one of their denial letters they came right out and said they'd cover the RNY if I wanted it. No, thank you. :D

TraumaNurse · 11-13-2004, 09:05 AM

I have BC/BS of massachusetts though and have recently found this on their website regarding WLS:
http://www.bcbsma.com/common/en_US/m...79.htm#billing

It gives billing codes.. I hope this helps.

~Christina:Bunny

**Jack** · 12-27-2004, 06:53 PM

Pacificare readily agreed my comorbidity factors made WLS the only rational choice.
They tried to insist on RnY....my internist helped convince them such an extreme type of surgery to a DIABETIC constituted an unnecessary risk, since the Band has such a good record.... :devious ;) :banana :banana :banana

HarleyNana · 12-27-2004, 09:28 PM

I'm in VA and have this sorry ins called Mamsi, they don't have any type of obesity surgery in their contract and furthermore...the band is considered experimental because it is reversible. I was the 1st patient in a 100 mile area to have this done, (without a discount I might add), total out of pocket $15,750.00. At this point, I've lost 18 lbs, that equals $875.00 per pound, oh my!

Gigi001 · 01-03-2005, 02:15 PM

can't say what to do first, but I hear that with so many insurance companies you have to keep pushing them and pushing them. I'm in WI and "between" insurance companies and thinking of signing with BCBS here because I heard that they have paid for lap band in WI already. So once they pay for it, it's sort of the thin end of the wedge.

I'm not having surgery til the end of the month, but I can't wait. I'm so tired of fighting not to gain another 10 lbs, never mind lose 100.

04-18-2005, 08:35 AM

I have blue cross blue sheild Texas and it covers the band.....All I need is a letter from the doctor. I don't know why it would be a difference from state to state......call your insurance and see what they say. I will tell you I have a PPO and that would make a difference. Good Luck!

08-15-2005, 10:50 PM

Can you tell me how to go about starting the procedure for applying for aetna hmo certification?

Quote:

same problem with my carrier, Aetna, back in 2002. I eventually won on my third appeal, which was an external appeal provided through New Jersey's dept of insurance. I don't know if California offers a similar third-party review of carrier decisions, so you might want to find that out.

If you are willing to fight the carrier on the "experimental" label, it most definitely can be done. The chance of success largely depends on who will ultimately make the determination. Insurance carriers have internal medical review departments, but if everyone in that department is on the carrier's payroll you can bet they'll toe the party line. Aetna didn't hesitate a second to deny my first and second appeals of their initial denial, because it was their company policy to exclude banding no matter what. This was upsetting but not surprising.

But then the decision got taken out of their hands, and I quickly got a notice that their denial was overturned. The external review board didn't agree with Aetna's policy that the band was investigational/experimental, and now that some time has passed Aetna has even embraced the band a bit more than they used to. I think all carriers will come around, eventually.

If you don't want to wait you should just proceed with your request for precertification and then follow the carrier's instructions about appealing. If there is a possibility for external review at any point I'd say you have a decent chance of winning. If California does not provide for any external review of insurance carrier's decisions, then you'll likely be out of luck until BCBS of CA comes to the obvious conclusion that the band is neither investigational or experimental. How much time that could take is anyone's guess.

Just starting to explore options...help!!!

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