RNY to DS Revision Surgical Billing Codes Needed

[babs71958]

My work insurance rep will check into my plan to see if Cigna would cover a revision, IF I can supply her the codes used by the doctor to file the claim. I'll supply her with the medical necessity info, so if I can obtain the exact medical codes they would use to file the claim and then use those codes to see how Cigna would process the claims, I would be very appreciative.
I haven't contacted any vetted revision surgeons as of yet. Due to having 2 previous open surgeries and a BMI of 44, I would like to go to the most experienced, which from my research is Dr. K.
If my insurance would cover it, I would have it done sooner rather than later. If they do not, it will be a few years before I have the funds.
Thanks in Advance.
Barb

 

[DianaCox]

As far as I know, the revision codes are the same for revision vs. virgin DS. But Dr. K's office would be the place to ask - and please post the answers for future reference! Please indicate what your surgery is a revision from.

 

[babs71958]

K, Diana..Will do...TY

 

[babs71958]

FYI: The CPT code for RNY to DS revision from Dr. K's office is 43848.
ICD 0 or 10 are diagnosis codes that the physician can't give until he see's you in his office.

 

[DianaCox]

CPT 43848:
Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)

 

[babs71958]

CPT code didn't matter. Cigna still won't cover it, "it's not in the plan".
Back to the drawing board.

 

[DianaCox]

They often lie - what does that mean "not in the plan?" Tell them to put it in writing, and send it to Larra and me.

Is your plan self-funded or fully funded? (You will have to ask your HR department) What state?

 

[babs71958]

This is what my rep emailed to me:
I then called Cigna concerning the CPT code for the weight loss surgery you were inquiring on. I was informed that this CPT code would not be a covered benefit. Your Doctor can start a pre-certification with Cigna based on the medical necessity of this procedure to see if it would be approved, but I was advised that any kind of gastric bypass surgery is not covered by the plan.
I emailed the rep back asking her the above questions. I'm in Ohio, which if I wanted an individual plan through Cigna, couldn't get it. I only have it now because it's through my former employer through COBRA.
My pain mgmt doc said he'd sign anything I needed as far as disability goes. But I don't think he could supply what Cigna would need to start the pre-certification process. What won't help is that I don't currently have a PCP. My appt with a new one is 9/22.
Would I need to fly out to see Dr. K to start the pre-cert process?

 

[DianaCox]

I'd need to review a copy of your Evidence of Coverage document - it should be something about 100 pages long and specific to your plan. If you have a self-funded plan that EXCLUDES any coverage for bariatric surgery, you may be SOL.

You would need to contact Dr. K to find out how to start the pre-cert process - but you should see whether you even have any chance at all from understanding what is and isn't covered. If ANY bariatric surgery is covered, it is possible that you can force them to cover the DS, even if they don't want to - in most cases, they can't restrict you from having a standard of care procedure just because they don't want to cover it.

 

[babs71958]

I tried to download the EOC from Cigna's website tonight, but it is down...again. Those sites go down more than I do, I swear!!!

 

[Spiky Bugger]

I tried to download the EOC from Cigna's website tonight, but it is down...again. Those sites go down more than I do, I swear!!!

But no one enjoys it...

 

[babs71958]

Update:
I'll be dropping Cigna after 8/31/14. I qualify for Ohio Medicaid. With no income currently, this is the route I need to take. I haven't given up the dream of a revision to a DS. It's just going to take longer than anticipated. Thanks for all your input and assistance thus far.