Re: Paritally Approved by Aetna !?

September 22, 2001

My comments below are enclosed with " >>> " and " <<< " for clarification...

Paritally Approved by Aetna !?

After review of the medical documentation submitted, the Claim

Medical Management medical staff has determined that the proposed

surgical treatment of obesity, choleystecomy, and liver biopsy

qualify as covered benefits under the provisions of the Plan. The

>>>This makes it sound like the proposed operation is covered...<<<

criteria for the surgical treatment of obesity are met. However,

Aetna US Healthcare does not cover any o f the following procedures

because the peer reviewed medical literature shows them to be either

unsafe or inadequately studied:

· Loop gastric bypass

· Gastroplasty using staples to create a small pouch

· Duodenal Switch Operation

· Biliopancreatic Bypass

· Laprascopic adjustable silicone gastric banding using the LAP-

BAND

>>>...but isn't the " proposed operation " the BPD/DS, in which case, isn't it

excluded??<<<

However, it has been determined, based on all the information

provided, that partial removal of the stomach, appendectomy, and

insertion of the tube into jejunum will not be a covered benefit

under the provisions of the plan.

Therefore, the Plan will not cover the proposed partial removal of

the stomach appendectomy, and insertion of tube into jejunum.

This determination for approved surgical treatment of obesity,

choleystectomy, and liver biopsy is valid for 90 days from the date

of the letter. Services not performed within this period require a

new review and are subject to guidelines in effect at this time.

Should an inpatient confinement become necessary, precertification

may be required. Please refer to the member's identification card for

further information.

>>>This is a strange letter...it sounds like they're saying that you're a

candidate for obesity surgery, but the one you want is excluded. Weird.

~alyssa <<<

September 22, 2001

Alissa,

Indeed it is a strange letter. I think that Dr. Anthone wrote it up a

distal gastric bypass, and that part is approved (though I am not

sure). I will find out on Monday.

Hull

> My comments below are enclosed with " >>> " and " <<< " for

clarification...

>

> Paritally Approved by Aetna !?

>

> After review of the medical documentation submitted, the Claim

> Medical Management medical staff has determined that the proposed

> surgical treatment of obesity, choleystecomy, and liver biopsy

> qualify as covered benefits under the provisions of the Plan. The

>

> >>>This makes it sound like the proposed operation is covered...<<<

>

> criteria for the surgical treatment of obesity are met. However,

> Aetna US Healthcare does not cover any o f the following procedures

> because the peer reviewed medical literature shows them to be either

> unsafe or inadequately studied:

> · Loop gastric bypass

> · Gastroplasty using staples to create a small pouch

> · Duodenal Switch Operation

> · Biliopancreatic Bypass

> · Laprascopic adjustable silicone gastric banding using the LAP-

> BAND

>

> >>>...but isn't the " proposed operation " the BPD/DS, in which case,

isn't it

> excluded??<<<

>

> However, it has been determined, based on all the information

> provided, that partial removal of the stomach, appendectomy, and

> insertion of the tube into jejunum will not be a covered benefit

> under the provisions of the plan.

>

> Therefore, the Plan will not cover the proposed partial removal of

> the stomach appendectomy, and insertion of tube into jejunum.

>

> This determination for approved surgical treatment of obesity,

> choleystectomy, and liver biopsy is valid for 90 days from the date

> of the letter. Services not performed within this period require a

> new review and are subject to guidelines in effect at this time.

> Should an inpatient confinement become necessary, precertification

> may be required. Please refer to the member's identification card

for

> further information.

>

> >>>This is a strange letter...it sounds like they're saying that

you're a

> candidate for obesity surgery, but the one you want is excluded.

Weird.

>

> ~alyssa <<<

September 22, 2001

it really sounds like they're basically

approving a RNY instead of the DS.

I agree with another poster, if anyone can convince

them it's YOU.

Good luck,

dee

p.s. How can something that's been around since 1988

be experimental???

--- chull1@... wrote:

> Alyssa,

>

> No, that is a distal gastrectomy. A distal gastric

> bypass is like a

> standard RNY except that more of the intestine is

> bypased. It is also

> known as a long-limb RNY.

>

> Hull

>

> > But isn't the DGB a partial removal of the

> stomach, which they

> listed as an

> > exclusion?

> >

> > alyssa

> > Re: Paritally Approved

> by Aetna !?

> >

> > Alissa,

> >

> > Indeed it is a strange letter. I think that Dr.

> Anthone wrote it up

> a

> > distal gastric bypass, and that part is approved

> (though I am not

> > sure). I will find out on Monday.

> >

> > Hull