insurance covers it, employer does not?

ourloveisreal · 07-09-2007, 04:59 PM

questions:
Have any of you been in the situations where your insurance covers it but your employer did not? I was told that aetna covered it but Jabil circuit - my mothers company did not. I freaked out, cried ya know.. Then I called my surgeons office and explained it to her after talking to the insurance lady. The lady at my surgeons office said Jabil might not cover bariatric surgery but that does not mean they wont approve it? Is there a super low chance Ill get approved now?
Confused..

faithmd · 07-09-2007, 05:05 PM

Yep, happens all the time. Aetna itslef will cover bariatric surgery IF the company who you get your insurance through (in your case, Jabil) purchases a rider to pay for it. If Jabil's policy has an exclusion to bariatric surgery, you will NOT get it paid for. The insurance people at your surgeon's office are good, I'm sure, but they have literally hundreds of insurances they deal with, they are not experts on yours. I urge you to get out your card and call the customer service number on it. Tell them you want to have adjustable gastric banding done and ask if they have a special procedures case manager who takes care of the bariatric cases that you can speak with. If not, then speak to whoever can help you figure out if they cover it and if so, what the requirements are. Have a pen and a pad of paper handy, write down the name of every person you speak to and note the date and time. Make notes of what they say. Most big companies have case managers that deal exclusively with special procedures like this. If not, then with the codes below, you should be able to get somewhere with the rep you talk to.
The codes to ask if they are covered are:
laparoscopic surgical adjustable band:Procedure code 43770; diagnosis code 278.01
Once you have found out from them if they cover it and what the requirements are, ask them to snail mail (and email if they can) you a copy of those requirements.

Good luck!

ourloveisreal · 07-09-2007, 05:17 PM

what card are you talking about? My insurance card or..

faithmd · 07-09-2007, 05:53 PM

Yes, your insurance card. It will have your group number on it and the toll free number that you need to call to find out these answers.

Marimaru · 07-09-2007, 07:27 PM

If the surgery is excluded by your employer, you'll need to appeal to HR (or your mom, I guess) to try to have it paid. I have heard of people doing this before.

rredding · 07-19-2007, 04:13 PM

I just called Aetna and within 10 min they let me know that, yes it was on my policy, and directed me to their clinical policy bulletins (you want 0157)