Aetna Denial IOQ Help

[Annacampo]

Hi I had a lap band removed in July after 13 yrs, due to not functioning properly which I hear is common. I'm in the process of going for revision to bypass every hoop has been jumped and today Insurance said it denied my surgery because the hospital my DR is affiliated with is not in their IOQ (institute of quality) list. The rep told me to tell my DR to ask for a peer to peer review. Mind you the band removal was done by this DR at this same hospital 4 mths ago... does anyone have any experience with this or any advise? I'm waiting to hear back from my DR's office at the moment

 

[galaxygrrl]

I'm so sorry about this. Wish there was more I knew to help you. I hate Aenta, I had coverage from them, but it was so awful and restrictive, I ended up self paying in Mexico because it was much, much less.

DianaCox and Larra our the local insurance experts. They should chime in. If not reach out to them.

Good luck.

 

[aaa]

Tagging @Larra and @DianaCox

 

[Larra]

I have never heard of an "institute of quality" list before. I've heard of "center of excellence" but not this, and I agree that if your surgeon was on said list 4 months ago it would be strange if he weren't on it now. Do you have a written denial? If not, get one, so that you know any and all reasons for the denial. And ask whoever handles insurance at your surgeon's office for an explanation as well, and whether you are the only Aetna patient being denied or is this happening to others, etc.
It also seems to me that if your surgeon or the hospital is not on the right list, a peer-to-peer doesn't make sense. This is usually a way to demonstrate medical necessity for the proposed operation and has nothing to do with being on some list.
I will just throw in for your consideration, though, that the whole mess may turn out to be a blessing in disguise if you decide to take this delay as an opportunity to learn more about all your revision options, specifically revision to the DS rather than to gastric bypass. The DS has much better statistics than bypass for percentage excess weight loss, for maintaining that weight loss (regain is a major problem with bypass) and for resolution of almost all comorbidities. It also allows people to take NSAIDs safely, has almost no risk of dumping, and no list of foods you can never eat again. This website has a lot of good info about the DS; take advantage of this and read all about it. Meanwhile, see if you can get more info about this denial so we can help out.

 

[Annacampo]

Aetna does have a "Institutes of
Quality® facilities fact book" where it discusses the requirements for a facility to qualify or become part of the IOQ list but nowhere does it state that its a requirement for coverage. I couldn't add link on here. it is referred to along side center of excellence. I spoke to DR's office they've never heard of it and said they have several other patients that have Aetna and this hasn't come up and are currently performing surgeries at the same hospital with Aetna... Im going to call them tomorrow again and try to speak to a manager. When I did the band removal they denied me because they couldn't find the hospital in their system as in network but I found it quite easily on their dr find turns out it was their error. Not the most upto speed ppl making these life changing decisions. I don't have a written denial yet. Thanks for advise, I've done a great deal of research and I will stick with bypass.

 

[DSRIGGS]

Obviously it is your decision but there are so many people here who have had their RnY revised to a DS because it failed. I made a huge mistake with my DS because I thought I researched well. Well my research was not good enough because I went with a surgeon who screwed me up I had to have my DS revised because he made my alimentary limb way too short and it caused severe malnutrition . had I done a better job I would known not to with Dr Marshall in Peoria and instead traveled to Dr Keshishian in California. it was the worst decision of my life and my health has suffered horribly because of it.

BTW I am an advanced degree holder so course I thought my research impeccable. It was not.

Oh, a good friend had a RNY and lost 450 lbs. Sadly he gained every bit of it back.

Anyways, it is your decision but I would be remiss if I didn't advise to you to take another look at the DS.

Best wishes

 

[Larra]

It sounds like some low level employee of your insurer cranked out a denial that was not justified. This happens a lot, I'm sorry to say, but it sounds like you have a handle on that issue and you (and/or the insurance person your surgeon employs) will get Aetna to correct this. This type of crap goes on all the time, because your insurer's goal is to make money, not to make sure you get medically necessary care.

 

[Susan in Tennessee]

Aetna does have a "Institutes of
Quality® facilities fact book" where it discusses the requirements for a facility to qualify or become part of the IOQ list but nowhere does it state that its a requirement for coverage. I couldn't add link on here. it is referred to along side center of excellence. I spoke to DR's office they've never heard of it and said they have several other patients that have Aetna and this hasn't come up and are currently performing surgeries at the same hospital with Aetna... Im going to call them tomorrow again and try to speak to a manager. When I did the band removal they denied me because they couldn't find the hospital in their system as in network but I found it quite easily on their dr find turns out it was their error. Not the most upto speed ppl making these life changing decisions. I don't have a written denial yet. Thanks for advise, I've done a great deal of research and I will stick with bypass.

I'm really curious as to your reasons for choosing gastric bypass.

 

[Annacampo]

I'm really curious as to your reasons for choosing gastric bypass.

For one thing the bypass has been the most effective and for the longest period of time of the bariatric surgeries. It also doesn't remove the separated portion of the stomach as does the DS & Sleeve and having a sweet tooth it will force me to stop eating sugar & certain fats. Also it's more for BMI's that are btw 35 to 55 which is what I fit into so I feel it would work better for me. DS is for higher BMI's the DS has higher incidents of complications than the other procedures and has a higher risk of malnutrition ppl report they loose too much weight. I did well with the band for almost 13 yrs I went from 250lbs to 135lbs but unfortunetly it didn't have the 10+ yr research at the time and it stopped working properly and that's another issue I have with DS & Sleeve not enough long term research avail yet.

 

[DSRIGGS]

With all due respect I hate to tell you but you have received some erroneous information.

No long term DS data - Really???? Dr Hess did the first DS in 1988. Since the 90's Dr Ara Keshishian has done over 2,500 DS procedures including over 500 RnY to DS revions because yes the RnY has a very high failure rate. BTW, Dr K is the best bariatric surgeon in the world and he will not do a RnY because to quote him, "all I did during my residency was fix failed RnY GBP's".

RnY most effective - The RnY GBP is not the most effective surgery. See the following chart from Dssurgery.com:

The DS is the Platinum Standard for Bariatric surgery and frankly the only WLS that works. The RnY has terrible long term statitistics so I don't know who convinced you it was the best or that the DS hasn't been around for long.

Where did you get the idea that the RnY GBP is for BMI's between 35 - 55 and the DS isn't? Let me guess, from a surgeon who doesn't do the DS? The person who runs this board had a BMI of barely over 35 and had the DS over 5 years ago and is doing quite well.

If you think forced dumping, which you could very well get with the RnY, is a good thing then I don't know what to tell you because it supposedly quite miserable and debilitating from what I have heard others say. The DS has no dumping. It will make you have atrocious gas and painfully bad gas that can leave you doubled over, if you eat too many simple carbs like sweets.

Please research the DS more and get the proper information before writing it off. Revising to anything but the DS after having another WLS is not a wise decision. We have all kinds of people on this board and on FB groups who revised from a failed RnY to the DS, or from a sleeve to the DS.

 

[southernlady]

For one thing the bypass has been the most effective and for the longest period of time of the bariatric surgeries. It also doesn't remove the separated portion of the stomach as does the DS & Sleeve and having a sweet tooth it will force me to stop eating sugar & certain fats. Also it's more for BMI's that are btw 35 to 55 which is what I fit into so I feel it would work better for me. DS is for higher BMI's the DS has higher incidents of complications than the other procedures and has a higher risk of malnutrition ppl report they loose too much weight. I did well with the band for almost 13 yrs I went from 250lbs to 135lbs but unfortunetly it didn't have the 10+ yr research at the time and it stopped working properly and that's another issue I have with DS & Sleeve not enough long term research avail yet.

My starting BMI was 35.2. I had 68 excess lbs to lose. My lowest was 121 (20.8 BMI) for 10 seconds and I have now settled in at 148-150. (25.4-25.7 BMI). I will be 6 years out on the 24th of Jan 2017. My ONLY regret...not doing it much sooner.

According to the NIH (and Medicare) if you meet the criteria for the RNY you also meet the criteria for the DS. I know many lightweight DS'ers and all of us have done awesome. And most do not lose too much weight. You can also lose too much weight with the RNY by that same argument. It's also a malabsortive procedure. But most RNY'ers I know eat sweets and fat. If you are counting on aversion therapy and dumping to avoid those foods, you are not ready for any surgery. Only about 30% of RNY'ers dump. Yes, it's more than the normal population but it's still not a guarantee.

All malabsorptive surgeries have a risk of malnutrition. The chance of a well educated and pro active DS'er suffering from malnutrition is very slim. I get my labs done every 6 months and adjust my vitamins according to my own lab work.

The first DS was done in 1988. That is closing in on 30 years. I know a few 20 year vets, many over the 15 year mark. Two articles:
https://www.ncbi.nlm.nih.gov/pubmed/15479938 (referencing the study done in 2004)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929999/

My first surgeon had the stupid idea that the DS was for those with a 50 BMI or higher. I fired him. Found a surgeon willing to do the DS on a lightweight cause I KNEW it was the best surgery for me. I require NSAIDS. I do not function well without them. IF I had had the RNY, I would be forever banned from taking NSAIDS.

 

[Larra]

I've seen that sweet tooth argument before, and it's a false argument. First, dumping has never been shown to be a weight loss tool or even an adjunct to the gastric bypass tool. It is a potentially very nasty side effect that some people with gastric bypass get - not all, though statistics as to the exact percentage of people who get it are all over the board, meaning no one really knows. There is no way to predict ahead of time who will dump and who won't. Different people dump with different foods - some with sweets, some with fat, some both, many neither. And a few unfortunate souls dump with all sorts of healthy foods. Dr. Keshishian has done revisions from gastric bypass to DS for people with uncontrollable dumping that was causing malnutrition.

You research seems to include the information a gastric bypass surgeon is telling you to sell you on gastric bypass. In reality, the long term statistics are available for both operations, and the DS has the best statistics of any bariatric surgery not just for percentage excess weight loss, but also for maintenance of that weight loss (which is crucial) and for resolution of almost all comorbidities. Even with the generous definition of "success" in the bariatric surgery world of losing just 50% of your excess weight, gastric bypass has a failure rate of about 30%. That's a high failure rate IMHO, and even at that, people who lose, let's say, 55-60% of their excess weight are classed as successes, even when they are still obese or MO. Add to that never being able to take NSAIDs again - and remember, even if you don't need them now you may as you get older - and the misery (NOT benefit!) of dumping - and there is just no real argument that favors gastric bypass.

I've met people IRL with gastric bypass who dump and still manage to eat around their dumping and regain weight. This is not just a theoretical point of view, it's reality. Do what you want, but at least know the truth about these operations. And take a good, honest look at yourself - what if you don't dump, and then you're stuck with an operation known to be less effective? What if you DO dump and it doesn't help?

And the stuff about DS being only for people with higher bmi? Pure BS. The DS is a standard of care bariatric operation for anyone who qualifies medically for bariatric surgery, and works just fine for lightweights. With either operation, if you don't take the necessary vitamins and eat your protein you will get into trouble. The actual rate of nutritional complications with the DS is very low and almost always due to noncompliance. It's up to each of us to make that commitment, but again this is true with either operation. You can get into plenty of trouble with gastric bypass, it just takes longer.