Stressing over Insurance requirements

[Liza Brooke]

hi everyone! My name is Liza and I’ve recently started the process of revising to. DS. I was sleeved in 2011 and lost about 80 lbs (my SW was 240). Over the last 7 years, I’ve gained back all of my weight. I’m currently 230 lbs and 5’0. My current BMI is 44. I have sleep apnea and bad back/hip/leg pain from my weight. My upper gi showed moderate gerd and a stretched out sleeve. I am scheduled for my endoscopy on Friday. Had my psych consult and initial nutrition visit today. My Dr office (Dr. Bonanni in Abington, PA) said they can submit for pre-cert after my next nutrition appt next month. I discovered my insrmiramce policy online tonight and it says a BMI of 50 is required for DS surgery. It also says that if it’s a staged procedure, the DS needs to be done within two years of VSG surgery.

Is this something that can be appealed successfully?? What about the one WLS per lifetime requirement?? I am going to call my employer tomorrow to request my EOC. Just want to know if it even worth going through with this. I am stressed out and worried and have just started. Thanks so much for any advice you can offer!!

 

[DianaCox]

Does your policy say there is a one WLS per lifetime restriction? If not, don't worry about it. The "staged procedure" doesn't apply to you - you were supposed to be a VSG as a definitive procedure, but the procedure failed, because it is rarely a definitive procedure for someone who has metabolic issues.

The restriction of the DS to BMI >50 is without medical evidence and is against the ASMBS position statement. We can help you argue against it as being arbitrary and capricious. It will likely require that you exhaust your internal appeals and go to Independent Medical Review. Is your insurance plan self-funded or fully funded? Ask your HR department. It's likely to not be easy, but we win this kind of appeal most of the time.

 

[southernlady]

Welcome Liza Brooke

Do what DianaCox suggests as she has appealed these before. You have to do the work but they (her and Larra) are behind you with the advice that has been successful numerous times.

 

[Liza Brooke]

Thanks for the quick response!! I contacted my HR today to get my EOC and they sent me something else. They also gave me the number of a Beniserve advocate, who was contacting Amerihealth for me today. I am prepared to appeal this.

My question is whether or not my insurance allows multiple surgeries. A coworkers wife tried to revise from a band to a sleeve and was denied based on one wls per lifetime. If this truly is the case, is there any way around it?!

 

[DianaCox]

Your question is too vague. We don't know why SHE was denied. From what I copied from the bariatric surgery policy, it appears to depend on your prior employment at the time you had surgery, as well as the REASON your surgery failed.

 

[hilary1617]

Hi and welcome Liza Brooke ! Best wishes that you will be able to get DS covered!

 

[galaxygrrl]

Best wishes. There is always the self-pay option. I think I DS revision is 8K with Dr Esquerra. But, hopefully your insurance will take care of it.

 

[Liza Brooke]

DianaCox

Here is what my EOC says (#32)

For treatment of obsesity,exceptforsurgicaltreatmentofobesitywhenthePlan (a) determines the surgery is Medically Necessary; and (b) the surgery is limited to one surgical procedure per lifetime regardless of whether such procedure was covered by the Plan or another Plan. Any new or different obesity surgery, revisions, repeat, or reversal of any previous surgery are not covered. The exclusion of coverage for a repeat, reversal or revision of a previous obesity surgery does not apply when the procedure results in technical failure or when the procedure is required to treat complications, which if left untreated, would result in endangering the health of the Covered Person.


What is considered technical failure?? Sounds like I’m screwed

 

[Larra]

have you had any testing done to see what condition your sleeve is in? The only way around this that I can think of is if there is something wrong with your sleeve. When bariatric surgeons first jumped on the sleeve bandwagon, some of them didn't get all the technical details right, having assumed that, if they could do a gastric bypass, surely they were competent to do the easier sleeve. And it IS easier, but you still have to do it right. But unless you have some documented problem with your sleeve, I don't know how you can get around this. My personal opinion is that this type of policy should not be legal. There is NO other medical condition where a one operation or one course of treatment per lifetime exists, and many conditions where more than one operation or treatment is necessary. But I don't rule the world and apparently this is legal. The AMSBS has also come out against these policies, but they don't rule the world either.

I hope you are open to considering Dr. Esquerra in Mexico, and that you can afford it. If you have any appeals rights - which would also be outlined in your EOC - you can give it a shot, but with the understanding that there is no guarantee of success.

 

[Liza Brooke]

I am scheduled for an EDG in July. My upper GI showed that my sleeve is significantly larger than it should be. I’m thinking an endoscopy will confirm this. What could be wrong with my sleeve? Does dilation count As a technical failure?? I’m so disappointed.

 

[DawnNYC]

I’m so sorry you’re policy is discriminatory and unhelpful. I’m not sure that it’s something you will be able to get around. But, of course, I’m not an expert in these matters.

Most employers offer 2-3 insurance options. Is there another insurance company you could switch too? If not, there are some great self-pay option with small monthly payment financing. I know it’s can be scary to take on debt, but we are talking about your health - both mentally and physically - and your quality of life.

Don’t give up if this is what you want. Take a moment to feel any emotion you’re feeling, then stand up and go get what you want!

You can do this!

 

[DianaCox]

(1) This is a pretty rock-solid looking exclusion. However, we can argue that your sleeve was not formed properly, and/or that you were given the option of having a DS, which clearly would have been a more appropriate surgery for you, so you were not able to give fully informed consent; we can also argue that although the sleeve was thought to be a viable definitive procedure when you had surgery, recent long term data has demonstrated that for the majority of people, just like with the lapband, a restrictive-only procedure is likely to be insufficient. You followed the post-op requirements, but this inadequate surgery failed you; you didn’t fail the surgery. But understand that the odds are probably less than 50% that you will win.

(2) Self pay.

(3) Get another job.

 

[Liza Brooke]

Thanks everyone for the replies. I’m so upset about this. It’s so not fair that insurance can do this. Obesity is a lifelong condition. These policies are descriminatory.

Is this a battle even worth fighting?? Could an EDG show something that could be helpful??

 

[Larra]

Liza, I'm sorry to say that I doubt the endoscopy will show a complication that will meet the requirements of your policy, but would recommend that you do it anyway, it part because it will help determine whether or not you need a re-sleeve with your DS (where ever you end up having it) and in part because you just never know.