Hello I am new here.....

[Karla Jenkins]

They have to MAIL it to me sad face. They do not have a copy on the site.

 

[aaa]

@Karla Jenkins Hello.

 

[Karla Jenkins]

@Karla Jenkins Hello.

Hi

 

[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.

Cant post a linky. I copied the info that it says.


I read the the information but it does not say any of the rules I have been told. It says nothing about needing to have revision to get my fistula fixed. It says nothing about 6 months of RD meetings or any thing like that. I am 100% confused. This is what it says

Services for Residents of Designated Counties For Members who reside in a California county designated as having facilities contracting with Blue Shield to provide bariatric services (see the list of designated counties below), Blue Shield will provide Benefits for certain Medically Necessary bariatric surgery procedures only if: 1) performed at a Participating Hospital or Ambulatory Surgery Center, and by a Participating Physician, that have both contracted with Blue Shield as a Bariatric Surgery Services Provider to provide the procedure; 2) the services are consistent with Blue Shield’s medical policy; and 32 3) prior authorization is obtained, in writing, from Blue Shield’s Medical Director. Blue Shield reserves the right to review all requests for prior authorization for these bariatric Benefits and to make a decision regarding Benefits based on: (1) the medical circumstances of each patient, and (2) consistency between the treatment proposed and Blue Shield medical policy. For Members who reside in a designated county, failure to obtain prior written authorization as described above and/or failure to have the procedure performed at a Participating Hospital or Ambulatory Surgery Center by a Bariatric Surgery Services Provider will result in denial of claims for this Benefit. Services for follow-up bariatric surgery procedures, such as lap-band adjustments, must also be provided by a Physician participating as a Bariatric Surgery Services Provider. The following are the designated counties in which Blue Shield has designated Bariatric Surgery Services Providers to provide bariatric services: Imperial San Bernardino Kern San Diego Los Angeles Santa Barbara Orange Ventura Riverside Bariatric Travel Expense Reimbursement For Residents of Designated Counties Members who reside in designated counties and who have obtained written authorization from Blue Shield to receive bariatric services at a Hospital or Ambulatory Surgery Center designated as a Bariatric Surgery Services Provider may be eligible to receive reimbursement for associated travel expenses. To be eligible to receive travel expense reimbursement, the Member’s home must be 50 or more miles from the nearest Hospital or Ambulatory Surgery Center designated as a Bariatric Surgery Services Provider. All requests for travel expense reimbursement must be prior authorized by Blue Shield. Approved travelrelated expenses will be reimbursed as follows: 1) Transportation to and from the facility up to a maximum of $130 per round trip: a) for the Member for a maximum of 3 trips: i) one trip for a pre-surgical visit; ii) one trip for the surgery; and iii) one trip for a follow-up visit. b) for one companion for a maximum of two trips: i) one trip for the surgery; and ii) one trip for a follow-up visit. 2) Hotel accommodations not to exceed $100 per day: a) for the Member and one companion for a maximum of two days per trip: i) one trip for a pre-surgical visit; and ii) one trip for a follow-up visit. b) for one companion for a maximum of four days for the duration of the surgery admission. Hotel accommodation is limited to one, double-occupancy room. Expenses for inroom and other hotel services are specifically excluded. 3) Related expenses judged reasonable by Blue Shield not to exceed $25 per day per Member up to a maximum of four days per trip. Expenses for tobacco, alcohol, drugs, telephone, television, delivery, and recreation are specifically excluded. Submission of adequate documentation including receipts is required before reimbursement will be made. 33 Services for Residents of Non-Designated Counties Bariatric surgery services for residents of nondesignated counties will be paid as any other surgery as described elsewhere in this section when: 1) services are consistent with Blue Shield’s medical policy; and, 2) prior authorization is obtained, in writing, from Blue Shield’s Medical Director. For Members who reside in non-designated counties, travel expenses associated with bariatric surgery services are not covered.

 

[Larra]

This is just a general statement about being in-network, center of excellence, travel, that sort of thing. What you need is the specific criteria for coverage for bariatric surgery in general, things like minimum without comorbidities, minimum bmi with comorbidities, passing a psych eval, separate requirements for revision, what specific operations are covered, which are excluded because they are considered experimental. That should all be in the EOC.
and appeals rights, if any.

 

[Karla Jenkins]

This is just a general statement about being in-network, center of excellence, travel, that sort of thing. What you need is the specific criteria for coverage for bariatric surgery in general, things like minimum without comorbidities, minimum bmi with comorbidities, passing a psych eval, separate requirements for revision, what specific operations are covered, which are excluded because they are considered experimental. That should all be in the EOC. and appeals rights, if any.

would it be a different document???

 

[Karla Jenkins]

is this what is needed??

This is just a general statement about being in-network, center of excellence, travel, that sort of thing. What you need is the specific criteria for coverage for bariatric surgery in general, things like minimum without comorbidities, minimum bmi with comorbidities, passing a psych eval, separate requirements for revision, what specific operations are covered, which are excluded because they are considered experimental. That should all be in the EOC.
and appeals rights, if any.

Is this what is needed???


Revision Bariatric Surgery The first (or a subsequent) revision surgery to address perioperative or late complications of a bariatric procedure may be considered medically necessary, provided that these complications include, but are not limited to: • Staple-line failure or leakage • Obstruction, stricture, erosion, or fistula • Gastroesophageal reflux disease (GERD), based on ambulatory pH probe monitoring, or endoscopic findings of ulcer, strictures, Barrett’s esophagus, or esophagitis and failing maximal medical therapy • Symptomatic pouch enlargement (recurrent vomiting or nausea) • Nonabsorption resulting in hypoglycemia or malnutrition • Weight loss of 20% or more below ideal body weight • Band slippage or herniation that cannot be corrected with manipulation or adjustment Revision of a primary or a subsequent bariatric procedure that has failed due to inadequate weight loss may be considered medically necessary when all of the following are met: • All initial primary bariatric surgery qualification criteria have been satisfied, including: o BMI greater than 40, or BMI greater than 35 with comorbid condition for most recent 2 years o No recent (less than 1 year) treatment for drug abuse o No recent tobacco use (less than 6 weeks) o Psychologic clearance o Preoperative nutritional counseling Reproduction without authorization from Blue Shield of California is prohibited 7.01.47 Bariatric Surgery Page 3 of 57 o Participation in a medically managed exercise and dietary program for 3 consecutive months o Ineffective weight loss attempts within 1 year prior to revision of surgery • Two years have elapsed since prior bariatric surgery • Inadequate weight loss resulted from initial procedure; less than 50% expected weight loss and/or weight remains greater than 40% over ideal body weight (normal body weight BMI parameter = 18.5-24.9) • Compliance with previous post operative nutrition plan and exercise program is documented

 

[Settledownnow]

Welcome @Karla Jenkins! I had a revision from RNY to DS and also had a fistula. The difference is that none of my pre-op tests showed the fistula. I was approved for revision regardless, and it was quite a surprise to learn of the fistula after surgery. You are in a much better position having that information if you need to fight your insurance company for coverage. I'm glad you are doing your research and have rejected distal RNY.

 

[Karla Jenkins]

This is just a general statement about being in-network, center of excellence, travel, that sort of thing. What you need is the specific criteria for coverage for bariatric surgery in general, things like minimum without comorbidities, minimum bmi with comorbidities, passing a psych eval, separate requirements for revision, what specific operations are covered, which are excluded because they are considered experimental. That should all be in the EOC.
and appeals rights, if any.

Please provide the following documentation (if/when requested): Bariatric Surgery in Adults with Morbid Obesity: • History and physical and/or consultation notes including prior weight loss attempts and responses, and comorbidities: o Co-morbidities, including, but not limited to: (when BMI is greater than or equal to 35.0 kg/m2 and less than 40.0 kg/m2 )  If diagnosed with coronary artery disease: Submit documentation from cardiologist that includes all previous and current treatments, as well as, member’s current status  If diagnosed with diabetes: Submit documentation from primary care provider or endocrinologist that includes all previous and current treatments, as well as, type of diabetes  If diagnosed with hypertension: Submit documentation from primary care provider that includes all previous and current treatments, as well as, member’s current status  If diagnosed with obstructive sleep apnea: Submit official sleep study report interpreted by a sleep disorders specialist MD or Doctor of Osteopathic (DO) medicine and documentation of all conservative therapies attempted with duration and outcomes  If diagnosed with osteoarthritis: Submit documentation from primary care provider that includes radiographic reports  If diagnosed with hyperlipidemia: Submit documentation from primary care provider/cardiologist that includes all previous and current treatments  If diagnosed with GERD: Submit documentation from primary care provider or gastroenterologist that includes all previous and current treatments, as well as, any endoscopic findings • Description of non-surgical weight-reduction program, initial weight, end weight, duration (start and end dates) • Time lapse between the initial bariatric consultation and date of surgery (recommended 3 months) • Documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure • Medical doctor (MD) order for surgery that includes current height, weight, and body mass index (BMI), surgery requested and recommendation • Documented educational counseling/class • Signed Bariatric Surgery Decision Aid • Signed CollaboRATE survey • Signed Psychosocial-behavioral checklist • Signed Pre-operative checklist Revision and Repeat Bariatric Surgical Requests: • History and physical and/or consultation notes including: prior surgery and complications (if applicable), indication for surgery, and treatment plan Reproduction without authorization from Blue Shield of California is prohibited 7.01.47 Bariatric Surgery Page 53 of 57 • Post-surgical weight loss history (including pre- and post-surgical BMI), nutrition and exercise compliance • Operative report(s) (if applicable) • Diagnostic radiology, endoscopy, or contrast study reports (if applicable)



Definitions of Decision Determinations Medically Necessary: A treatment, procedure, or drug is medically necessary only when it has been established as safe and effective for the particular symptoms or diagnosis, is not investigational or experimental, is not being provided primarily for the convenience of the patient or the provider, and is provided at the most appropriate level to treat the condition. Investigational/Experimental: A treatment, procedure, or drug is investigational when it has not been recognized as safe and effective for use in treating the particular condition in accordance with generally accepted professional medical standards. This includes services where approval by the federal or state governmental is required prior to use, but has not yet been granted. Split Evaluation: Blue Shield of California/Blue Shield of California Life & Health Insurance Company (Blue Shield) policy review can result in a split evaluation, where a treatment, procedure, or drug will be considered to be investigational for certain indications or conditions, Reproduction without authorization from Blue Shield of California is prohibited 7.01.47 Bariatric Surgery Page 57 of 57 but will be deemed safe and effective for other indications or conditions, and therefore potentially medically necessary in those instances. Prior Authorization Requirements (as applicable to your plan) Within five days before the actual date of service, the provider must confirm with Blue Shield that the member's health plan coverage is still in effect. Blue Shield reserves the right to revoke an authorization prior to services being rendered based on cancellation of the member's eligibility. Final determination of benefits will be made after review of the claim for limitations or exclusions. Questions regarding the applicability of this policy should be directed to the Prior Authorization Department. Please call (800) 541-6652 or visit the provider portal at <there is a link here that I removed> . Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. Blue Shield of California may consider published peer-reviewed scientific literature, national guidelines, and local standards of practice in developing its medical policy. Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over medical policy and must be considered first in determining covered services. Member contracts may differ in their benefits. Blue Shield reserves the right to review and update policies as appropriate.

 

[Larra]

Given that you have a documented fistula, my interpretation is that you meet their criteria for a revision. So the remaining issue is finding a surgeon to do it, and if there is no in-network surgeon qualified to do what is needed, they can be forced to pay (with usual co-pays) for an out of network surgeon. I would recommend that you still get the mailed copy of EOC as it will be easier to refer to (and read!) and also that you start a private conversation with me and with @DianaCox so we can communicate more easily, and also so personal details can be kept private.

 

[DianaCox]

Revision Bariatric Surgery The first (or a subsequent) revision surgery to address perioperative or late complications of a bariatric procedure may be considered medically necessary, provided that these complications include, but are not limited to: • Staple-line failure or leakage • Obstruction, stricture, erosion, or fistula • Gastroesophageal reflux disease (GERD), based on ambulatory pH probe monitoring, or endoscopic findings of ulcer, strictures, Barrett’s esophagus, or esophagitis and failing maximal medical therapy • Symptomatic pouch enlargement (recurrent vomiting or nausea) • Nonabsorption resulting in hypoglycemia or malnutrition • Weight loss of 20% or more below ideal body weight • Band slippage or herniation that cannot be corrected with manipulation or adjustment

I believe the above is the only part that matters. The following is irrelevant, because it relates to revision solely based on inadequate weight loss.

Revision of a primary or a subsequent bariatric procedure that has failed due to inadequate weight loss may be considered medically necessary when all of the following are met: • All initial primary bariatric surgery qualification criteria have been satisfied, including: o BMI greater than 40, or BMI greater than 35 with comorbid condition for most recent 2 years o No recent (less than 1 year) treatment for drug abuse o No recent tobacco use (less than 6 weeks) o Psychologic clearance o Preoperative nutritional counseling Reproduction without authorization from Blue Shield of California is prohibited 7.01.47 Bariatric Surgery Page 3 of 57 o Participation in a medically managed exercise and dietary program for 3 consecutive months o Ineffective weight loss attempts within 1 year prior to revision of surgery • Two years have elapsed since prior bariatric surgery • Inadequate weight loss resulted from initial procedure; less than 50% expected weight loss and/or weight remains greater than 40% over ideal body weight (normal body weight BMI parameter = 18.5-24.9) • Compliance with previous post operative nutrition plan and exercise program is documented
​

Can you explain WHY your surgeon believes a revision is needed at the same time as the fistula is repaired? The reason may or may not support (1) waiving any further documentation requirements, and (2) revising to DS being even better than distal revision.