Hello all! I had posted on another site and was kindly directed to this site by a helpful poster. I posted in Insurance and am cross-posting here. Hope that's okay! Here's my predicament:
Part 1
I had RNY 11 years ago. While I was a "remedial loser" from day 1, I did manage to get down to around 195. Over the last 2 years, I've been steadily gaining even though I've upped exercise with a personal trainer and have watched my diet. I saw my surgeon and he found (through an endoscopy) that my pouch is just fine but my stoma is large (he may have said "huge"). We discussed options and he is suggesting a revision to DS. After tons of research here, I agree.
Aetna has denied me. My insurance policy has no mention of WLS or even the term "bariatric" but Aetna insists my company has it listed as an exclusion. This is the terminology in my policy under Exclusions:
24. Obesity – Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a part of the treatment plan for another Sickness. Medically Necessary charges for Morbid Obesity will be covered.
It seems like that last part implies that surgery should be covered. I'm bummed because I could have taken my husband's insurance (BCBS IL PPO) but chose mine thinking it was better (and reading it to make sure there was no bariatric exclusion). I contacted a health advocate and while she agrees it doesn't make sense, she got the same answers. I'll have to wait until January to switch to my husband's policy and even then won't find out for sure if they cover it after I'm a policy holder. I'm curious if anyone else has encountered this?
Thanks in advance. I hope to join you all on the DS side some day.
Part 2 (happened this morning)
I met with my the HR person at my HEALTH CARE company that manages our benefits today. Indeed, we are self-insured and our plan is sponsored by AETNA. I told her my issue and pointed out where it says "Medically Necessary charges for Morbid Obesity will be covered" in the Summary Plan Description (printed out all 105 pages of it - trees forgive me) which is posted on our company intranet. She just kept saying "bariatric surgery is not covered", over and over. She seem just a smidgen annoyed with me.
I also told her that if bariatric surgery is not covered, the language in the document is misleading. "Bariatric surgery" is never mentioned in the document but many other specific exclusions are (cosmetic surgery, vitamins, etc.). My surgeon's office does not accept self-payment for this procedure, so I have no options. I asked her if the company could terminate my policy so I can buy insurance thru the IL health exchanges and she said no. I feel like they've tied my hands.
She also kept saying that the coverage choices is based on benchmarks and medical direction from experts. She seemed surprised when I told her that even the health exchanges (in IL) cover bariatric surgery. She seemed annoyed that I told her that the AETNA rep told the patient advocate that my company chooses not to cover bariatric surgery.
So, as it stands, my HR person is reaching out to AETNA for more information. She asked me to supply the "CPT codes" from my surgeon. I have a call in to his office. I'm hoping because of the "RNY failure" (enlarged stoma issue), and because it's something has to be corrected, something may happen with AETNA. I'm afraid they'll come back with the decision that they'll cover the charges for the stoma to be fixed but they won't cover the revision to a DS. She told me they don't "override the policy" for individual cases.
Thanks for listening/reading. I welcome any other thoughts or ideas on this. Thank you again!
Jeannie
Part 1
I had RNY 11 years ago. While I was a "remedial loser" from day 1, I did manage to get down to around 195. Over the last 2 years, I've been steadily gaining even though I've upped exercise with a personal trainer and have watched my diet. I saw my surgeon and he found (through an endoscopy) that my pouch is just fine but my stoma is large (he may have said "huge"). We discussed options and he is suggesting a revision to DS. After tons of research here, I agree.
Aetna has denied me. My insurance policy has no mention of WLS or even the term "bariatric" but Aetna insists my company has it listed as an exclusion. This is the terminology in my policy under Exclusions:
24. Obesity – Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a part of the treatment plan for another Sickness. Medically Necessary charges for Morbid Obesity will be covered.
It seems like that last part implies that surgery should be covered. I'm bummed because I could have taken my husband's insurance (BCBS IL PPO) but chose mine thinking it was better (and reading it to make sure there was no bariatric exclusion). I contacted a health advocate and while she agrees it doesn't make sense, she got the same answers. I'll have to wait until January to switch to my husband's policy and even then won't find out for sure if they cover it after I'm a policy holder. I'm curious if anyone else has encountered this?
Thanks in advance. I hope to join you all on the DS side some day.
Part 2 (happened this morning)
I met with my the HR person at my HEALTH CARE company that manages our benefits today. Indeed, we are self-insured and our plan is sponsored by AETNA. I told her my issue and pointed out where it says "Medically Necessary charges for Morbid Obesity will be covered" in the Summary Plan Description (printed out all 105 pages of it - trees forgive me) which is posted on our company intranet. She just kept saying "bariatric surgery is not covered", over and over. She seem just a smidgen annoyed with me.
I also told her that if bariatric surgery is not covered, the language in the document is misleading. "Bariatric surgery" is never mentioned in the document but many other specific exclusions are (cosmetic surgery, vitamins, etc.). My surgeon's office does not accept self-payment for this procedure, so I have no options. I asked her if the company could terminate my policy so I can buy insurance thru the IL health exchanges and she said no. I feel like they've tied my hands.
She also kept saying that the coverage choices is based on benchmarks and medical direction from experts. She seemed surprised when I told her that even the health exchanges (in IL) cover bariatric surgery. She seemed annoyed that I told her that the AETNA rep told the patient advocate that my company chooses not to cover bariatric surgery.
So, as it stands, my HR person is reaching out to AETNA for more information. She asked me to supply the "CPT codes" from my surgeon. I have a call in to his office. I'm hoping because of the "RNY failure" (enlarged stoma issue), and because it's something has to be corrected, something may happen with AETNA. I'm afraid they'll come back with the decision that they'll cover the charges for the stoma to be fixed but they won't cover the revision to a DS. She told me they don't "override the policy" for individual cases.
Thanks for listening/reading. I welcome any other thoughts or ideas on this. Thank you again!
Jeannie
