Insurance Approval for BPD/DS needed for BMI under 50 how???

Discussion in 'Insurance' started by Vicki A, Jun 11, 2018.

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    Vicki A

    Vicki A New Member

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    Hi there! I have Tricare and they require a BMI of 50+ to approve for BPD/DS. My BMI is currently around 44, but this is the surgery I would really like to have. Is there any way to fight this, or things to do, ask the surgeon etc. or reasons that I would possibly be approved with a lower BMI. I have been researching both VSG & RNY, and since this is an "elective surgery" I would like to really be able to have the procedure I want.

    Thank you!
     
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    southernlady

    southernlady Administrator Staff Member

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    mcnee

    mcnee Member

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    You can have any surgery you want... if you're the one paying for it. Insurance companies, for the moment, are able to put arbitrary restrictions and requirements on the procedure if you want them to pay for it.

    That said, many (if not most) surgeons would agree that DS should only be done on patients with very high (50+ BMI), the risk/reward of the DS over the RNY when BMI is under 50 just doesn't justify it for most doctors.
     
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    southernlady

    southernlady Administrator Staff Member

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    My BMI was 35.2 (with comorbids). Those of us who are DS lightweights don’t consider the unjust arbitration of a 50 BMI logical. The NIH and Medicare say anyone who qualifies for WLS qualifies for any standard of care option. The DS is one of those.
     
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    hilary1617

    hilary1617 First time at the rodeo.

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    Hi and welcome Vicki AVicki A ! Well done for doing the research and pursuing the DS, which has the proven best long term weight loss results of all surgeries and is entirely appropriate for a BMI of 44. Don't settle for less. I hope Diana and Larra are able to assist.
     
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    DianaCox

    DianaCox Bad Cop

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    You are most likely going to have to deal with the bariatric group at Madigan in Washington state. http://www.mamc.amedd.army.mil/news/2018/05/31/bariatric-program-earns-international-accreditation

    However, even after all this time, I can’t say for sure whether there is an appeals process that can be deployed if the surgeons there say no. Most everyone has just self-paid. We’d be happy to help you try to fight it.

    The way to start would be to find out how to get a consult with them. That may be the choke point, of course - without the required BMI, maybe you can’t get a consult with one of the DS surgeons. It can’t hurt to ask.
     
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    mcnee

    mcnee Member

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    I understand the 50BMI cutoff is arbitrary and that some may not agree with it.. but if that's what her insurance company is saying, if they don't cover it, they don't cover it. There is no appealing. And many insurance policies do not cover the DS. period.

    It sucks how the insurance companies put so many barriers to treatment. The Obesity Action Coalition is currently starting the process of taking the insurance companies to court in NY State over the requirement of 6 months of supervised weight loss before surgery. That's just one example of an arbitrary barrier.
     
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    DianaCox

    DianaCox Bad Cop

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    “I understand the 50BMI cutoff is arbitrary and that some may not agree with it.. but if that's what her insurance company is saying, if they don't cover it, they don't cover it. There is no appealing. And many insurance policies do not cover the DS. period.”

    Actually, with all due respect, you're wrong. I’m an attorney and I’ve been helping people overcome these kinds of denials (starting with my own) for 15 years, pro bono. The ONLY reason I have any doubt about this particular case is because it’s TriCare and not a regular state or ERISA-regulated plan. I’m not sure we’ve ever gotten someone to appeal with TriCare, since for the most part, the person would have to travel anyway, so many opt for self-pay in Mexico. But appealing is a way to pressure even TriCare to change policies, and the surgeons at Madigan are actually pro-DS so I wouldn’t be surprised if they were willing to help.
     
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    mcnee

    mcnee Member

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    well that's great to hear Diana... but isn't there a difference between a policy not covering something and appealing a denial? Either way... glad to know some thing may be able to be done.

    There may be other changes in the wind as well. A surgeon I work with said something tonight that struck a chord... the original BMI guidelines were made years ago, when surgeries were done open. The BMI's were, in part, chosen to balance the benefits of surgery against the risks. Now that surgeries are much safer since being done laparoscopic, many feel it's time to revisit those guidelines. The ASMBS just release a position paper on the use of surgical intervention in BMIs as low as 30.... primarily in those with type-2 diabetes, but also as a general treatment for Class 1 Obesity.
     
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    DianaCox

    DianaCox Bad Cop

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    You can appeal an exclusion in several ways, especially if you have either a good state insurance commission or a decent employer in a self-funded plan. You can claim the surgery is treatment for something else; you can show the exclusion is wrong or out of date; etc.; or in the case of a self-funded plan, ask them to make an exception for you. Of course, ~60% of the time, they’ll uphold the exclusion-based denial, but if you don’t appeal it, that percentage is 100%. And if enough people appeal a shitty exclusion, they might change the rule. That’s paying it forward.
     
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    Spiky Bugger

    Spiky Bugger Well-Known Member

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    You "sound" very confident in your assertions. Too bad they are so wrong.

    I have no idea why you have decided to start sharing what you know about bariatric surgery (and insurance) (and marriage, for that matter), but I sure wish you'd master some facts first...because it would be good if you knew a lot more.
     
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    DianaCox

    DianaCox Bad Cop

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    mcneemcnee - I see from your profile that you are 9 years postop from an RNY. There are some other RNYers here, but many of us are a core of strong veteran advocates for the DS, and are far more knowledgeable about the science of bariatric surgery as well as insurance law than the surgeons and their insurance staff. For example, I will be 15 years out on August 5th, and I have a PhD in molecular biology as well as being an attorney. There are other scientists, MDs, nurses and nutritionists here too. We know what we’re talking about, more often than not.

    How are you doing? Are you researching a revision of your RNY? One of the reasons we are so pro-DS is that the long term results for RNY are so disappointing. Even the most diligent RNYers are usually struggling by 9 years out.

    It’s good to get new blood here, but you might want to consider whether as a newbie, you want to opine authoritatively on subject matter about which you may not be as up to speed as many if not most of us. Discouraging other newbies with false statements about the propriety of the BMI requirement and the ability to fight insurance denials/exclusionary policies - subject matter which a quick word search would show are frequent topics here, with many victories reported - is not helpful.

    TriCare is a tough one though.
     
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    Spiky Bugger

    Spiky Bugger Well-Known Member

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    Hey!

    You're supposed to be the Bad Cop.

    I, however, am loaded on Percocet, Cannabis (tincture, vape, gummy candy and--occasionally--salve) plus Voltaren, ice packs and (RARELY) an NSAID. My SI Joint is mega-inflamed, I've had one round of injections under fluoroscopy and, since they wait two weeks between injections, I'm in agony until at least Tuesday.

    That isn't an apology, of course. Perhaps more of an explanation as to why there will be no apology.

    (Also an explanation as to why we are having meal delivery 3x/wk and are thinking of upping that to every day.)

    BTW, my problem area is on the left side. If I lean wrong and put pressure in the wrong area, I go ballistic, emitting sounds that range from a roaring moan to a screeching yell. To get up off the couch, I have to scoot to the edge of the cushion, then bending over at the waist like someone not quite brave enough to actually dive into the pool, I lean onto and belly-crawl across the seat of a counter-height bar stool and try to lift myself from there. Once up, I can stand or walk fairly well. Getting back down hurts, but not like getting up.

    So after a recent time-consuming getting-up event, I looked at Mr. Sue and said, "I think I'm moving like a crab."

    He said, "No. Crabs move much faster."

    Gotta love that kind of support.
     
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    hilary1617

    hilary1617 First time at the rodeo.

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    I'm so sorry to hear this Sue. May Tuesday arrive swiftly along with durable, complete relief.
     
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    southernlady

    southernlady Administrator Staff Member

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    I’m sorry. Did you whap your hubby for his comment???
     

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