Paritally Approved by Aetna !?

[Guest guest]

Hi Folks,

Just received a partial approval from Aetna. It is a bit ambigous, as

it approves the gastric bypass procedure that Dr. Anthone requested,

yet it list among the excluded procedures the Duodenal Switch.

A copy is included below.

Hull

September 19, 2001

Dear Dr. Anthone

We have received your request for a predetermination of benefits for

Hull for the proposed surgical treatment of obesity,

cholecysectomy, liver biopsy, partial removal of the stomach,

appendectomy, and insertion of tub into the jejunum. Coverage is

provided for services or supply, which is necessary. A service or

supply furnished by a particular provider is necessary if Aetna US

Healthcare determines that it is appropriate for the diagnosis, care,

or treatment of the disease or injury involved.

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

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

Note: As a high incidence of gallbladder disease (28%) has been

documented after surgery for morbid obesity, Aetna US Healthcare

covers routine cholecystectomy in concert with elective bariatric

procedures. In addition a biopsy of the liver would also be eligible

for coverage.

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.

All covered expenses are subject to screening for contracted rates.

This is not a guarantee of benefits. Actual payment will be made on

the basis of the provider's reported service, the prevailing fee,

member eligibility, and all other plan provisions and limits at the

time the services are rendered.

Despite this determination about plan benefits, we want to emphasize

that the member and physician still make the final determination

whether the proposed treatment is performed.

You have a right to appeal this determination. If you decide to do

so, your or your authorized representative should submit any

additional information that you would like us to consider. We will

notify you in writing of our decision. If you disagree with the

appeal decision, you have the right to a second appeal.

Submit you appeal, along with a copy of this letter to:

Ramona E , MD

Medical Director

PO Box 54388

Los Angeles, CA 90054

If you have any question, please call our member services

representatives toll free at the phone number listed on the member's

identification cared.

Sincerely,

Ramona E , MD

Medical Director

REJ/ra