Insurance requires high BMI for DS?

Discussion in 'Duodenal Switch' started by Remingtonh, Jul 13, 2018.

  1.  
    DianaCox

    DianaCox Bad Cop

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    Here is another paper that demonstrates long- term need for revision. In this paper from Marceau’s practice in Canada, they have VERY good numbers on follow up due to their universal health care. This paper is from 2007, and had 10+ year results. I have the paper on my computer which is doing a long term cleanup process so I’m not supposed to mess with it right now, but I’ve linked to the abstract. Also, I don’t recall whether these numbers include the earliest patients who got a 50 cm CC, which they found was too short. The rest were 100 cm, IIRC.

    “The need for revision for malnutrition was rare (0.7%) and total reversal was exceptional (0.2%).”

    https://www.ncbi.nlm.nih.gov/m/pubmed/18219767/

    From the same group, a more recent (2016) shorter term study on their lap DS - out of 566 patients, TWO required revision for malnutrition (whole paper available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4722734/):

    “... reoperation was required in 0.5 % (Table 3), including two patients who required a surgical revision for malnutrition.”

    “In experienced hands” is the key takeaway. Personally, I’d go to Ayoola, because I think I’m worth it, especially if it’s just a matter of convenience, but you’ll probably be fine with Ganta.
     
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  2.  
    Munchkin

    Munchkin Full of Fairy Dust

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    This is not correct. Ask him to show you data to corroborate this statement. It does not exist.
     
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  3.  
    Remingtonh

    Remingtonh Well-Known Member

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    I think they were his own statistics...
     
  4.  
    Larra

    Larra Well-Known Member

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    If they are his own statistics, that does not speak well for the nutritional information he is providing to his patients. Either that, or it was just more scare tactics, like the 8K you would be out of pocket crap.
     
  5.  
    Munchkin

    Munchkin Full of Fairy Dust

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    I would bet he has not done more than 50 DS, tops. If those were his own statistics, he is not doing a good job. I have been in DS world for almost 20 years and I have seen thousands of patients come and go. Revisions to lengthen the CC, maybe 10 in that time.

    My CC is 75 and I wish it was 50!
     
  6.  
    DianaCox

    DianaCox Bad Cop

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    THINK TWICE, CUT ONCE! If his stats are that awful, GO SOMEWHERE ELSE!

    I'm sorry if you don't want to hear this, but I would be RUNNING away from Ganta if he said that to me. Either he sucks as a surgeon, or sucks at nutritional advice - or maybe he JUST REALLY DOESN'T WANT TO DO THE DS ON YOU. No matter which, WHY would you have any confidence in him?
     
  7.  
    JackieOnLine

    JackieOnLine Moderator Staff Member

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    :cautious:
     
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  8.  
    Remingtonh

    Remingtonh Well-Known Member

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    I'll ask Dr Ganta if he has an idea why a greater percentage of his DS surgeries result in revision, if in fact that is the case. I could have misunderstood that particular issue. We were discussing a lot of different things at that time.
     
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  9.  
    Whit

    Whit Well-Known Member

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    I prepaid Dr K’s fee for revision surgery. It was pre surgery but after insurance approval. I had no problem doing so. That was over 5.5 years ago.

    His staff is amazing. They did everything for me. All I did was provide insurance coverage contact information.

    Good luck
     
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  10.  
    DianaCox

    DianaCox Bad Cop

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    Just FYI - there is a difference between prepaying fees that are CERTAIN to not be covered (like Dr.K's program fee, copay, and a portion of the balance billing for an out-of-network procedure that is very unlikely to be covered). But to require a payment of a fee that has been preauthorized, in-network on the chance that the insurance company will RETROACTIVELY refuse to pay for the surgery, screams of warnings that the surgeon is not coding/doing the procedure he is submitting for (i.e., coding it as CPT 43845, but then doing a "non-standard" DS, as documented in the op report). Note this definition of CPT 43845:
    “43845 - Gastric restrictive procedure with partial gastrectomy, pylorus- preserving duodenoileostomy and ileoieostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)”​

    Longer common channels would not comply with this CPT.
     
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  11.  
    Remingtonh

    Remingtonh Well-Known Member

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    OK, so what Dr. Ganta told me - I'm sure i'm relaying this as I heard it - he may have simplified the explanation for my benefit though:

    His office submits the pre-authorization documentation using the code 43659 - "Unlisted laparoscopy procedure, stomach" along with supporting documentation for the Lap-DS.

    The insurance companies will all immediately authorize the procedure. This is almost guaranteed - it's authorized through an automated system at the insurance company.

    Once the procedure is done, and the claim is submitted for payment - the insurance company sees the unlisted CPT code, and denies the claim. It then goes to manual review - and the person/people manually reviewing it deny the claim, and ask for additional supporting documentation. This happens a couple times over (rinse/repeat), until finally the insurance company denies the claim for "not medically necessary." At this point it's a year or two after the surgery, and there is nothing more he can do.

    43845 is for open DS, not laparoscopic. I confirmed this with United Healthcare directly, by the way.

    I can't wait for Diana's response to this :)
     
  12.  
    Larra

    Larra Well-Known Member

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    Well, I'm not Diana, but she and I have helped people with insurance denials for the Ds for years now, and I know for sure that the 43845 code is the one used for the DS, whether it's done lap, open or lap hand assisted. Almost all DS surgeons routinely do them lap or lap hand assisted. And they get preauthorization, using this code routinely. And the don't get a denial a couple years down the line for doing the procedure lap.

    I'm sure Diana's response will be more strongly worded than mine, but I will agree with her, in advance, that this is crap.
     
  13.  
    DianaCox

    DianaCox Bad Cop

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    How about you ask UHC how the want it coded?
     
  14.  
    Remingtonh

    Remingtonh Well-Known Member

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    I did, they want it coded 43659. They said its not normally a problem. It's when I explained to Ganta that United Healthcare told me they want it coded with the unlisted code, that he decided to chance it and go ahead with the DS. I'm still pre-paying a deposit, but not the full amount, which I'm OK with.

    I'm just happy I'm getting the DS thanks to you all. Pending pre-authorization which I'm waiting for now. Today will be a calendar week of waiting.

    On the 19th, a day before my appt with Ganta, and after I told the office in no uncertain terms I wanted the DS and not the RNY, the billing staff submitted my paperwork to United Healthcare with the RNY code. I was peeved about that. They had to correct that on the 20th.
     
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  15.  
    JenniferIlse

    JenniferIlse New Member

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    I also have UHC. They approved my DS with a BMI of 42 with code 43845 for a lap DS with CC 150cm. I would be leery of submitting under the unlisted code, seems much more likely to get rejections when the claim is actually submitted. I had my done 7/11/18 and so far everything looks to be processing through and paying out appropriately. Just my 2 cents, drive to Ayoola. I have a local surgeon i could have gone to, but I drove hours away to go to dr Inman who is one of the vetted surgeons here. So many of the 9 people I had surgery with on that same week on July are struggling with nausea. Diarrhea, dehydration. I am doing great. Down 18 pounds, can drink easily, eat easily but small portions, the pain was well managed, my incisions look great and I have PEACE OF MIND since I am not worrying if my surgery was done incorrectly as some of the other folks are. It is worth it and it isnt a drive you have to make all that often. I have gone up 3 times, the consult, the preop testing and nutrition class, and the surgery. I will go up and 1, 4, 8 and 12 months for follow ups. I'd rather spend a week of days driving to and fro then have to possibly deal with excessive digestive issues. It doesnt have to be a bad/horrible surgery to not be a great one. There are lots of good surgeons but if you can get to a great one, do it.
     
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