Hello I am new here.....

[Karla Jenkins]

Hi.

I am looking to do a revision from RNY to DS. I was only wanting a Fistula I have repaired but my insurance says they will only cover it IF I have a revision. I started down the revision path and the DR wants to do a distal bypass. As I did research on that procedure I decided that I did not want to do that and as I asked questions I ended up here to get information.

At this point I am lost on what to do next. The insurance says to get my problem fixed I have to have a revision but the revision that I want is not covered (none of the Drs that are contracted with my insurance do RNY--->DS). Not sure what my next step is.

 

[Charris]

hey Welcome! @DianaCox & @Larra can tell you what to do. they are the insurance gurus....

 

[Karla Jenkins]

Thank You so much...

 

[DianaCox]

If you need a procedure that is covered by your insurance, and there is nobody in-network who can do it, then your insurance company should have to pay for you to have the procedure by an out of network surgeon at the same cost to you as if it were an in-network surgeon.

You need to obtain a copy of your Evidence of Coverage document (this is your insurance contract, not a summary of benefits and should be around 100 pages long - you need to obtain from your HR department) and bariatric policy (may be in the EoC, may be a separate document) to see what their policy is on revision - there are often very harsh and nearly impossible to meet requirements, which can be appealed, but it's best to know what their expectations are first.

 

[Karla Jenkins]

If you need a procedure that is covered by your insurance, and there is nobody in-network who can do it, then your insurance company should have to pay for you to have the procedure by an out of network surgeon at the same cost to you as if it were an in-network surgeon.

You need to obtain a copy of your Evidence of Coverage document (this is your insurance contract, not a summary of benefits and should be around 100 pages long - you need to obtain from your HR department) and bariatric policy (may be in the EoC, may be a separate document) to see what their policy is on revision - there are often very harsh and nearly impossible to meet requirements, which can be appealed, but it's best to know what their expectations are first.

Thank You. Is it different for people who buy insurance on there own? Like thru a state exchange? I am about to move less a mile away but that puts me in a different county so I have the option to get a plan off exchange. I would get the same plan but just the off-exchange plan bc it has my current Dr as a PCP where as the on network plan he is considered a specialist.

 

[Larra]

First, hi and welcome and what @DianaCox said.
Next, you are in CA. See if you can get a plan where either Dr. John Rabkin of Pacific Laparoscopy in San Francisco, or Dr. Ara Keshishian in Glendale, is in network. These are the only 2 surgeons in CA who do RNY to DS revisions. Fortunately, both are excellent. But if you have no access to a plan with either of them in-network, what Diana said applies. And if you have a documented fistula, you have a strong justification for a revision, as this is an anatomic complication of your gastric bypass that you can't possibly correct yourself.
And for the record, revising to distal gastric bypass would do nothing to fix your fistula. Your pouch and blind stomach are what need to be fixed.

 

[DianaCox]

If you live in CA and have a state plan, you are most likely very fortunate - the CA Dept. of Managed Health Care is very much in favor of the DS. But we need to know what kind of plan you have. Please be specific.

 

[Karla Jenkins]

If you live in CA and have a state plan, you are most likely very fortunate - the CA Dept. of Managed Health Care is very much in favor of the DS. But we need to know what kind of plan you have. Please be specific.

I have the covered CA silver PPO. They say that there is no coverage for out of network bariatrics and neither Dr. K or Dr Rabkin are in network.

 

[DianaCox]

You can appeal that holding if there is no in-network surgeon who can do the procedure. I worked with my daughter's silver plan to get her out-of-network endometriosis specialist covered. It can be done. Or - you can change plans.

 

[Karla Jenkins]

First, hi and welcome and what @DianaCox said.
Next, you are in CA. See if you can get a plan where either Dr. John Rabkin of Pacific Laparoscopy in San Francisco, or Dr. Ara Keshishian in Glendale, is in network. These are the only 2 surgeons in CA who do RNY to DS revisions. Fortunately, both are excellent. But if you have no access to a plan with either of them in-network, what Diana said applies. And if you have a documented fistula, you have a strong justification for a revision, as this is an anatomic complication of your gastric bypass that you can't possibly correct yourself.
And for the record, revising to distal gastric bypass would do nothing to fix your fistula. Your pouch and blind stomach are what need to be fixed.

They said to get the fistula fixed I would have to get a revision at the same time. I don't get why I just wanted it fixed but now they sent me down this path...... I know i need to loose more weight but I was not looking for another surgery....

 

[Karla Jenkins]

It seems that none of the BS plans have either as a provider and the one plan that has Dr K as a provider is MUCH more expensive and they dont have my other Dr... What happens if I switch to health net? Do I have to start this whole awful process over again? It has taken me almost 7 months of pain to get to this point.

 

[galaxygrrl]

Work with @DianaCox and @Larra to appeal. It takes a few months, but they deliever results.

 

[Larra]

@Karla Jenkins we need to see your EOC (Evidence of Coverage), which is a huge document with all the details about what is covered, what isn't, and appeals rights. This is about 100 pages, not just a summary of benefits.
Keep in mind that you aren't just someone who wants a revision for weight loss, you are someone with a serious complication from prior bariatric surgery that needs to be fixed, AND that, apparently, your insurer has demanded that this include a revision. This puts you in a better position than a lot of people who have an operation that failed but no complication, in terms of getting surgery covered. So get that document and let's see what we have to work with. We can't advise you what to do next without knowing this information.

 

[southernlady]

Welcome @Karla Jenkins
What Diana and Larra said. Basically start a conversation with them and they can help you.

 

[Karla Jenkins]

@Karla Jenkins we need to see your EOC (Evidence of Coverage), which is a huge document with all the details about what is covered, what isn't, and appeals rights. This is about 100 pages, not just a summary of benefits.
Keep in mind that you aren't just someone who wants a revision for weight loss, you are someone with a serious complication from prior bariatric surgery that needs to be fixed, AND that, apparently, your insurer has demanded that this include a revision. This puts you in a better position than a lot of people who have an operation that failed but no complication, in terms of getting surgery covered. So get that document and let's see what we have to work with. We can't advise you what to do next without knowing this information.

Thank you I am trying to get it now.