Re: Paritally Approved by Aetna !?

[Guest guest]

>

> 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

was this your first response from Aetna? I know if anyone can

convince them that BDP/DS has not been performed enough or doesn't

have enough documentation, you can! I wish you luck in getting

everything covered by Aetna!

Carole

[Guest guest]

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

[Guest guest]

Dee,

Thanks for the vote of confidence. I have two major concerns. First,

a two-party dialog cannot exist at a level any higher than the less

inteligent of the individuals involved. I am not sure that the

reviewers at Aetna are intellegent enough to even understand basic

arguments. All of their documents are so hopelesssly confused and

misguided. I think they get their docs from the bottom of the class.

The second issue is time. My wife will be leaving for culinary

school in late December, and I can ill affoard a long drawn out

battle.

On the other hand I have my amunition loaded and am prepared if

necessary. I think that Anthone/Aetna have sort of worked out an

tacit agreement where Aetna pays for the RNY portion of the surgery

and the patient (us) gets stuck with the relatively small incrimental

costs.

I don't have proof of that, but I do know two others from Aetna that

have paid portions of the surgery and been covered for the bulk of

it. Both are currently unavailable (Mindy is on vacation, and

Wild just had surgery about 1 week ago). I guess I will have

to wait until Monday to find out.

The delemma is this, if I fight for full coverage then it would

probably involve disclosing the full details of the procedure, and I

might wind up with nothing covered.

I am waiting to hear from Dr. Anthone's office as well as the two

gals I mentioned in order to make a decision as to how I will move

forward.

For the moment I am relieved that they have at least responded with

something (however incomprehensible).

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

> >

> >

> >

> --------------------------------------------------------------------

--

> >

[Guest guest]

Alyssa,

It is probably a mistake to assume that insurance companies think

rationally. That being said, their seems to be some logic to it.

Aetna is willing to allow for the standard RNY gastric bypass along

with the modification of the standard RNY to a distal gastric bypass.

Aetna doesn't understand the similarity between the distal gastric

bypass and the biliopancreatic diversion. They are similar in

effect, but not the same. The BPD procedure removes part of the

stomach, whereas the distal gastric bypass cuts the bulk of the

stomach off and forms a stoma out of the top of the stomach.

Otherwise the intestinal configuration is much the same.

Although the BPD is explicitly NOT covered, a distal gastric bypass

is covered, and hence the stomach removal is considered not medically

necessary.

In fact the BPD and DGB (distal-gastric bypass) are rather similar in

function, though the BPD allows for larger gastric volume (and

usually emphisises the malabsorptive portion more than the DGB).

The duodenal switch confuses things even further. It also is

explictly NOT covered. Even though the DS is clearly a better

procedure than either the BPD without DS and the distal-gastric

bypass (and CPB 157 sort of admits it), Aetna just seems unprepared

to recognize it.

Somehow the minor modification of the proximal gastric bypass to a

distal gastric bypass is more comfortable to Aetna (besides which it

adds no cost). The fact that the malabsorptive properties are the

same or worse than the duodenal switch seems compleatly ignored.

So you need to think in a sorted twisted way to understand them.

They don't have a firm grip on the science, so they simply cling to

comfort.

Hull

>

> Re: Paritally Approved by Aetna !?

>

>

> > 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.

>

> Now I'm more confused than ever as to why that part would

be " okay, " but the

> other parts wouldn't.

>

> alyssa

[Guest guest]

Hi

I've heard its much tougher to the the DS approved.Why, I don't know.My

surgeon told me to expect a denial! He told me I could get around it though

since he is the only surgeon in NC and SC.So before I got denied I sat dwon

and a typed a letter to Cigna.I hope it helps.

Thanks,

in SC

[Guest guest]

I thinks its political and they like to play with your mind and heart. Se

how hard you will fight them.