Lapband Removal Approved; DS Denied!

[Joyouslyme]

BCBSIL approved my lapband removal and denied CPT codes 43775 and 44238 for the DS. The denials were compliance and vagueness of procedure related. My surgeon's office will request peer to peer when they receive the denial letter.
The coordinator stated that she did not send any of my history to the insurance company.
My background: I was banded in 2007. Lost 70 pounds. Lost my job and insurance in 2010. Got pregnant and had my daughter all in 2012. I didn't know that my new insurance covered my lapband. I started having esophageal issues in early 2015 and that's when a colleague told me that bariatrics is covered under my health plan.
Is there anything that I should be doing? I'm a firm believer in being proactive.

 

[southernlady]

Tagging @DianaCox and @Larra

 

[DianaCox]

"CPT codes 43775 and 44238 for the DS"​

Those are not the proper codes for the DS - the DS is 43845: "Gastric restrictive procedure, with partial gastrectomy, pylorus-preserving duodenoileostomy (50 to 100 cm common channel) to limit absorption (BPD/DS)" - no wonder you were denied.

Who is your surgeon? S/he should know better.

We need to see your Evidence of Coverage document (your COMPLETE insurance contract 80-100 pages long, NOT a benefit summary doc), as well as the bariatric surgery requirements for YOUR insurance plan. You need to find out whether your plan is self-funded or fully funded.

YOU are going to have to prove compliance somehow. It's not fair, but it is what it is. If you are trying to have a revision due to regain, you are going to have to show you were compliant. I would focus on your esophageal issues in your case.

 

[Joyouslyme]

Thanks. The coordinator said that she didn't think the full DS code would be approved if those codes weren't approved. Dr. Prachand left the codes up to her.

I work for one of the largest county governments in the country. I will call tomorrow for the EOC. The coordinator said that compliance is considered the first 2 years after surgery. I have that on file with my surgeon.

 

[DianaCox]

I don't understand using those codes. THERE IS A PROPER CODE FOR THE DS! Ask why they aren't using it!

 

[Joyouslyme]

I'm on it. I refuse to get cut two more times!

 

[Joyouslyme]

Ok @DianaCox , I have the EOC and my plan is self funded as of 12/1/15. It's very vague and in legalese. The gentleman from my benefits department is contacting our BCBSIL rep directly to get the information on revision surgeries. I emailed my surgeon's coordinator and asked her why the complete DS code wasn't submitted.