Written by Walter Lindstrom of PRIA Appeals
There are many patients out there, hoping to get approved for bariatric surgery very soon, who are living in fear that the number on the scale isn’t going to move the right way after they’ve completed their “mandatory” pre-surgery diet plan.
If you are one of these people, you may be asking yourself:
“What if I gain weight before bariatric surgery?”
“What if I lose weight, but it’s not enough to get approval for the surgery?”
Aetna in particular is causing a lot of people concern because their medical policy says: “The member must not have a net gain in weight during the program.”
Bariatric surgeons may ask a patient to go on a weight-loss program as surgery gets closer because it often helps make the operation safer, especially when done laparoscopically. That is a medical decision made by a qualified professional.
What I’m talking about here is very different. Insurance companies try to force people to lose weight to prove they are “worthy” of this medical care. Have you ever heard of any other chronic disease where the patient has to prove themselves worthy of the only effective treatment? Me neither!
The question is, how do we handle this unfortunate situation? It starts with the surgeon’s office. There are far too many bariatric programs that will refuse to submit the pre-authorization request if the patient has gained weight (or not lost enough). That is the wrong way to handle a patient’s medical care.
If your doctor will not submit the request, you can’t even appeal a denial of coverage. It is a real problem when bariatric programs give insurance companies the power to make decisions that are not in their patients’ best interests!
If you are a patient who finds yourself in this situation, you have two clear choices. You can choose to wait, keep dieting, and hope you lose enough weight to get your provider to submit the request to the insurance company, or you can fight.
One woman chose the latter option. She gained weight during her pre-operative program and Aetna deemed her unworthy of surgery. She had reasons, but they didn’t care. Her words describe her situation best:
“I was denied for vertical sleeve gastrectomy on July 7th. I was denied for a ‘net gain’ during the supervised diet. As I was getting ready for my three-month required visits, my husband, who is 37 years old, had a massive heart attack on Feb 6th. He needed a triple bypass. My world was turned upside down. He was back in the hospital after the open heart surgery because he acquired pneumonia.
I wrote all of this in my appeal letter that was sent out with his discharge paperwork on August 1st. I was denied for my appeal on August 18th. I’m lost, overwhelmed and simply tired. I’m just totally defeated right now.”
The question of whether her sleeve surgery was medically necessary was not a close call. Her BMI was nearly 47 and she had multiple health problems. But she gained weight, which went against Aetna’s criteria.
Shortly after Labor Day, we got started. We got her chart, reviewed the plan, evaluated the data and re-started her fight. On October 10, she was rewarded for not walking away, even though nobody would have blamed her if she did, because we obtained her approval. Kudos to her surgeon’s office, which submitted her case despite the weight gain, for they gave her a chance to fight. But more kudos to her because she did not stay “totally defeated.” Instead, we get the thrill of reading her reaction when she emailed Kelley after being told the news:
YOU JUST MADE MY YEAR!!
And Walter tooo!!
I am so happy I cannot thank you enough.
“Lost,” “defeated,” “overwhelmed,” “tired”—insurance companies count on those feelings stopping us from moving forward. Please don’t give in. The important thing to keep in mind is that there is always hope if you don’t give up. And 20+ years after my bariatric surgery I can tell you that what you stand to gain is worth the fight. You are worth it!
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