Bariatric exclusion as it applies to DS follow up care

[Smartycat]

I have received an amazing job offer. It is a 25% increase in pay but the medical insurance has a bariatric exclusion. I had surgery in April 2015. I am worried what this means for follow up care. I can budget for labs but worry about coverage if I needed surgery / hospitalization for a DS related complication. I received the Certificate of Coverage and the only thing I can see that relates to bariatric surgery is under exclusions it lists, "surgical and nonsurgical treatment of obesity". This job is an amazing opportunity but the insurance thing is really freaking me out. Any advice, thoughts?

 

[Clematis]

I wouldn't worry too much about it.

Keep reading your EOC. My policy excluded any WLS. But it didn't disallow treatment for complications if they occurred a month or later post-op. This was not under the WLS section but under treatment for pre-existing conditions, or emergency care for non-covered procedures or something.

An intestinal blockage can happen for ANY reason, not just from WLS. They can't prove that WLS caused it. Same thing for hernia repair.

Congrats on job offer!

 

[DianaCox]

Preexisting conditions are required to be covered by the ACA. BUT - look carefully at the Evidence of Coverage document to check whether the plan is self-funded and whether there are any grandfathered exclusions. There are very few of these old plans left, but an employer who would maintain this assholic and cruel of an exclusion, might be one of them.

In any case, your labs can be coded, with the cooperation of your PCP, as the current equivalent of ICD-9 579.9: non-specific intestinal malabsorption.

 

[Munchkin]

Don't worry! They are saying they won't do the surgery. Has nothing to do with care.

 

[Spiky Bugger]

And then there's this: Prove it.

I have SIBO, small intestine bacterial overgrowth. The main risk factors are:

• Low stomach acid
• Irritable bowel syndrome
• Celiac disease (long-standing)
• Crohn’s disease
• Prior bowel surgery
• Diabetes mellitus (type I and type II)
• Multiple courses of antibiotics
• Organ system dysfunction, such as liver cirrhosis, chronic pancreatitis, or renal failure

And some insurances would focus on the DS as "bowel surgery" to "blame" the DS as the cause of my SIBO. However, I have a hx of way too many antibiotics being prescribed and taken.

So, argumentative old bitch that I am, I would ask (demand) that they prove that the DS and NOT the antibiotics were the cause.

I suspect that most stuff that sends us to hospitals has multiple potential sources.

 

[DianaCox]

Hmm, the ICD-10 is quite different - but it is NOT bariatric surgery specific:


2017 ICD-10-CM Diagnosis Code K90

Intestinal malabsorption
2017 ICD-10-CM Diagnosis Code K90 5 codes below that describe this diagnosis in greater detail.

• This is the American ICD-10-CM version of K90. Other international versions of ICD-10 K90 may differ.

• Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

• Clinical Information
• A disorder characterized by inadequate absorption of nutrients in the small intestine. Symptoms include abdominal marked discomfort, bloating and diarrhea.
• A group of symptoms such as gas, bloating, abdominal pain, and diarrhea resulting from the body's inability to properly absorb nutrients.
• A syndrome resulting from the inadequate absorption of nutrients in the small intestine. Symptoms include abdominal pain, bloating, and diarrhea.
• General term for a group of malnutrition syndromes caused by failure of normal intestinal absorption of nutrients.
• Impaired absorption of nutrients in the gastrointestinal tract.
• Malabsorption: decreased absorption of fat and other nutrients caused by liver, biliary, pancreatic or intestinal disease. The 72-hour fecal fat determination is the best single test for mal- absorption.
• Your small intestine does most of the digesting of the foods you eat. If you have a malabsorption syndrome, your small intestine cannot absorb nutrients from foods.causes of malabsorption syndromes include
  
  • celiac disease
  • lactose intolerance
  • short bowel syndrome, which happens after surgery to remove a large portion of the small intestine
  • whipple disease, a rare bacterial infection
  • genetic diseases
  • certain medicines
  treatment of malabsorption syndromes depends on the cause.

Type 1 Excludes "Type 1 Excludes Definition|A type 1 excludes note is a pure excludes. It means "not coded here". A type 1 excludes note indicates that the code excluded should never be used at the same time as K90. A type 1 excludes note is for used for when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition."

• intestinal malabsorption following gastrointestinal surgery (K91.2
  
  )

*****

017 ICD-10-CM Diagnosis Code K91.2
Postsurgical malabsorption, not elsewhere classified

• 
  2016 2017 Billable/Specific Code

• K91.2 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
• This is the American ICD-10-CM version of K91.2. Other international versions of ICD-10 K91.2 may differ.
• Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Applicable To

• Postsurgical blind loop syndrome

Approximate Synonyms

• Malabsorption, postoperative
• Malnutrition following gastrointestinal surgery
• Malnutrition post GI surgery
• Postoperative malabsorption
• Post-surgical malabsorption
• Short bowel syndrome

Type 1 Excludes

• malabsorption osteomalacia in adults (M83.2Adult osteomalacia due to malabsorption

 

[southernlady]

Oh, and short bowel, while a result of surgery, is NOT always WLS.

My oldest step daughter had a bowel blockage due to a hysterectomy. Nope, NOT WLS.

My BFF's mother in law never had OR needed WLS. However, due to severe bowel blockage after colon surgery for cancer, she now has a 35 cm short intestine. (YES, I typed 35). My BFF is a member of a DS group to help keep her alive. We've convinced her to share her lab work with her and me so we can help her tweak those. At 85, she has a hard time with the "fat is not the enemy to good health" that she's been taught most of her adult life. She's having a hard time staying away from carbs...she's doing better since I had a heart to heart at Memorial Day when we finally met face to face. Told her while carbs are not completely off the table, she needed to severely limit them.

She loves Fettuccine Alfredo. She was thinking the sauce was too rich and full of fat. I think we finally got her to realize it wasn't the sauce but the pasta that was giving her gas, bloat, and diarrhea.

So while they may exclude WLS, make them PROVE it was due to WLS.