A little about me....

[southernlady]

Here is the link I found outlining the steps to take if you are denied for insurance (so I can find it again - and in case anyone else is interested): deleted by admin

You are welcome to turn it into a pdf and post here but I only allow links to sites that allow our links in return.

 

[southernlady]

Here is a link to one of members appeal timeline. https://bariatricfacts.org/threads/my-insurance-ordeal-for-the-ds.6129/

 

[Annemarie]

You are welcome to turn it into a pdf and post here but I only allow links to sites that allow our links in return.

Thank you for telling me that....if that's stated somewhere, I totally missed it (or else forgot, in light of all the info I'm taking in....). I will check into making it a PDF, because I do think it's good info to have here.

 

[southernlady]

I agree it’s good info but linking is discouraged with othe forms who don’t return the favor. Websites that are not forums, especially well known ones like dsfacts.com and Vitalady, we allow those types pretty much no restrictions.

 

[Annemarie]

I agree it’s good info but linking is discouraged with othe forms who don’t return the favor. Websites that are not forums, especially well known ones like dsfacts.com and Vitalady, we allow those types pretty much no restrictions.

Awesome - thanks again!

The link was, in fact, from DSFACTS.com, which you said in your response was allowed with no restrictions - so I'm a little confused. But no worries as I did a search on the title to find it again and am going to save the information in a word document so I can follow it.

 

[southernlady]

Awesome - thanks again!

The link was, in fact, from DSFACTS.com, which you said in your response was allowed with no restrictions - so I'm a little confused. But no worries as I did a search on the title to find it again and am going to save the information in a word document so I can follow it.

For that, use the link to dsfacts and then tell which article.

 

[galaxygrrl]

In terms of the insurance paying for the VSG and then paying for the DS, look at the numbers. I think a revision in MX from VSG to DS is about 8K and the full thing is 11K. And it's two operations.

 

[Annemarie]

In terms of the insurance paying for the VSG and then paying for the DS, look at the numbers. I think a revision in MX from VSG to DS is about 8K and the full thing is 11K. And it's two operations.

I clearly have a lot of research to do. I am a little on info overload tonight. I think I'm going to do the sleep study, since I'm pretty sure I have apnea and should get that taken care of regardless. And I'm going tomorrow night to the seminar with the main guy of the practice (the one with the DS experience).

I DID confirm today that insurance will not cover a 2-phased approach - so that bit from the surgical consult was BS. PLUS - why would I ever subject myself to 2 surgeries if I can do one? Anyhow - so much to think about and I appreciate you taking the time to share your thoughts! I think I might also invest in an out of pocket consult with Dr. Alverdy in Chicago....just to get a different perspective.

 

[Spiky Bugger]

Hi. I’m Sue...and compulsively snoopy and was actually in Military Intelligence back in the day. Glad I left before the end result was having to plead guilty to something. Anyway...

So I went to some other wls site. I went to the DS forum. I searched for “Guske” in the DS forum. Nada. Zip. So then, for comparison purposes, I searched for “Keshishian.” There were 65 results.

This, on one of the largest wls sites on the interwebz, could mean:
1–his DS patients sign NDAs; or,
2–he performs few, if any, DS surgeries; or,
3–I misspelled his name; or,
4–absolutely nothing.

ALSO, Larra stole all my good ideas. As in...if you are considered “too healthy” for the DS with a BMI of 40...and lose weight...see where the problem is? And the one wls per lifetime (no matter who paid for it) rule. And then, because I argue for fun, WHO TF SAYS the RnY is medically necessary and the DS is not? Some administrative assistant in their customer service department? It certainly is NOT the opinion of the ASMBS.

So, keep doing your homework. Welcome.

 

[Annemarie]

Here's a summary of what I've learned:
1. BC/BS IL's medical policy does not cover DS for BMI <50. (confirmed fact)

2. BC/BS IL's medical policy does not cover a 2 phased approach (i.e., sleeve now, switch later) - unless during the DS procedure there is medical reason to STOP. (confirmed fact)

3. I went, as requested by the bariatric coordinator, to the 2nd seminar with Dr. Kane (the son of the guy who is the namesake of the Kane Center). He is (allegedly) the doc in the practice who does the DS most often. Overall, his presentation was a little more scientific than the other guy (Rantis, the one my endocrinologist recommended) - but he sang the same tune as both Rantis and Guske....recommended 2 phased approach; DS only for BMI >50...blah blah. I met with the bariatric coordinator face to face while there, telling her i was still doing research and was leaning towards the DS. She repeated that my insurance does not cover DS for BMI <50, and suggested I consider the RNY if I didn't want the sleeve. I told her I wanted to pay cash for the DS (as a test - I don't have that kind of cash laying around) - and she said the hospital wouldn't allow payment out of pocket for a surgery not covered by insurance. (not sure whether that is actually true or not - because I'm fairly certain I don't trust this practice anyhow so it doesn't matter).

4. Meanwhile, their office sent me a package of info for their bariatric program, indicating I have been preapproved/authorized by insurance for a sleeve gastrectomy (do they not listen? but i guess - it's good to start with being approved for SOMETHING). (spoiler alert: even if I can't get approved for DS, I won't be having a sleeve gastrectomy with them)

5. I called Dr. Alverdy down at U of C. Jeremy the phone-answerer was not nice. Gave him my info, BMI, weight, height, comorbidities (he also asked if I could walk, or if I needed a wheelchair, cane or walker - which was new)....he said their bariatric coordinator would call me back within 4-5 business days if I'm eligible so I can sign up for another "seminar". I explained that I've already been to two, and understand the various weight loss procedures so well I might could deliver a seminar on the topic myself - and that I really didn't want to have to sit through yet another seminar. He said it would be up to the coordinator. And so - now I'm waiting again.

 

[southernlady]

Here's a summary of what I've learned:
1. BC/BS IL's medical policy does not cover DS for BMI <50. (confirmed fact)

THAT part can be fought.

Is yours thru an employer and is it self funded? DianaCox can explain why that's important.

 

[Annemarie]

THAT part can be fought.

Is yours thru an employer and is it self funded? DianaCox can explain why that's important.

It's through my employer. Unsure how to ascertain whether self-funded or not? Do I just call and ask? Or is there some other way?

Also, upon a review, it seems that the information sent by the Kane Center (Guske, Kane, Rantis) - it's actually a list of all the things I have to do prior to scheduling my sleeve gastrectomy. (do they just not listen to me?) That aside - should I still do all the things, because they'd be needed no matter WHICH procedure? Or should I wait and get into see Alverdy first? Part of me thinks that I should get cracking on it, to save time....but the other part of me thinks that a new doctor would want the stuff done under his/her watch?

 

[southernlady]

It's through my employer. Unsure how to ascertain whether self-funded or not? Do I just call and ask? Or is there some other way?

Also, upon a review, it seems that the information sent by the Kane Center (Guske, Kane, Rantis) - it's actually a list of all the things I have to do prior to scheduling my sleeve gastrectomy. (do they just not listen to me?) That aside - should I still do all the things, because they'd be needed no matter WHICH procedure? Or should I wait and get into see Alverdy first? Part of me thinks that I should get cracking on it, to save time....but the other part of me thinks that a new doctor would want the stuff done under his/her watch?

Wait....
The Kane Center isn't listening giving the impression that they don't care.

My husband started at the same office I did but he went to Dr. Pomp in NYC, I had mine in TN. We had two different policies. My secondary policy was BCBSTN Medicare which had minimal requirements and paid 100% after the year's deductible. My primary policy was the same as his, UHC, so all my bills had to be presented to UHC to be denied and forwarded to BCBSTN Medicare. His was paid.

What happened was I failed to meet the UHC criteria his employer put in place of 5 years of documented 35+ BMI. Unfortunately, I was so close that several years, I'd be a 34.9 or 34.8 instead of a 35. He, OTOH, had five solid years above 35.

Now the surgeon's office stated he had to do a 6 month diet/visits. His policy did NOT. They insurance coordinator at Dr. Boyce's office was quoting UHC's GENERIC standards which his company had overridden. I have NO clue if his was self funded or not but we took GREAT pleasure in sticking his copy of the EOB in her face! But he moved on cause they only wanted to do the sleeve on him and he needed the DS as bad as I did. In fact, he was told by Boyce's partner that he would never get under 200. His lowest weight after was 147 and he was scrawny. Wearing a 28 waist, He wears a 34 waist now and looks fine. His highest weight since he hit normal BMI back in Oct 2011 was 198. He and I both agree he could lost 10 lbs but not hard enough to make an issue of it.

 

[Spiky Bugger]

Here's a summary of what I've learned:
1. BC/BS IL's medical policy does not cover DS for BMI <50. (confirmed fact)

2. BC/BS IL's medical policy does not cover a 2 phased approach (i.e., sleeve now, switch later) - unless during the DS procedure there is medical reason to STOP. (confirmed fact)

3. I went, as requested by the bariatric coordinator, to the 2nd seminar with Dr. Kane (the son of the guy who is the namesake of the Kane Center). He is (allegedly) the doc in the practice who does the DS most often. Overall, his presentation was a little more scientific than the other guy (Rantis, the one my endocrinologist recommended) - but he sang the same tune as both Rantis and Guske....recommended 2 phased approach; DS only for BMI >50...blah blah. I met with the bariatric coordinator face to face while there, telling her i was still doing research and was leaning towards the DS. She repeated that my insurance does not cover DS for BMI <50, and suggested I consider the RNY if I didn't want the sleeve. I told her I wanted to pay cash for the DS (as a test - I don't have that kind of cash laying around) - and she said the hospital wouldn't allow payment out of pocket for a surgery not covered by insurance. (not sure whether that is actually true or not - because I'm fairly certain I don't trust this practice anyhow so it doesn't matter).

4. Meanwhile, their office sent me a package of info for their bariatric program, indicating I have been preapproved/authorized by insurance for a sleeve gastrectomy (do they not listen? but i guess - it's good to start with being approved for SOMETHING). (spoiler alert: even if I can't get approved for DS, I won't be having a sleeve gastrectomy with them)

5. I called Dr. Alverdy down at U of C. Jeremy the phone-answerer was not nice. Gave him my info, BMI, weight, height, comorbidities (he also asked if I could walk, or if I needed a wheelchair, cane or walker - which was new)....he said their bariatric coordinator would call me back within 4-5 business days if I'm eligible so I can sign up for another "seminar". I explained that I've already been to two, and understand the various weight loss procedures so well I might could deliver a seminar on the topic myself - and that I really didn't want to have to sit through yet another seminar. He said it would be up to the coordinator. And so - now I'm waiting again.

Not sure, but I think Jeremy has been there forever...so, even if he deserves it, try not to piss him off until you're sure you don't want to go there. Just sayin'...

 

[Annemarie]

Not sure, but I think Jeremy has been there forever...so, even if he deserves it, try not to piss him off until you're sure you don't want to go there. Just sayin'...

Oh - you're totally right on. I sense that was part of his crabbiness - his flat affect when he spoke just smacked of complete and utter boredom - like he has been there forever and has dealt with people just like me forever and is, frankly, over us. Someone called me this afternoon and left a message (I was at the bank) - when I called back, I left all of my info. Good news - their seminar is a webinar, not an in-person thing, so at least it won't involve a trip all the way to the south side. So at least things are moving.