Bariatric exclusion and other questions.

[CristyA]

I am seeking RNY to DS revision. Aetna HMO (Phoenix)

When Bariatrics is on the list of exclusions on your policy does that generally include revision surgery or are those 2 separate things? I am working on getting the full policy document from my husband's employer but I don't have it available yet. The policy summary lists bariatrics in the exclusion list but then under that, it says: "covered when medically necessary" and includes a list of criteria for revision surgery (not virgin WLS). I called HR and Aetna but I am not confident in the information I got over the phone. (They both said they do not see any exclusions in the policy for Bariatric surgery and I would have to just meet the criteria for the procedure and get a pre-approval) Then why would the summary clearly have it listed under exclusions? I'm so confused.

I am pretty pessimistic but is it possible that it means they will look at each case individually to determine coverage for revision surgery?

One doctor's office I spoke to, Dr. Simper's office, I was told they are separate things and just because one is excluded doesn't mean the other is not covered. That office won't take me on as a patient because my original surgery (RNY) was in MX. They said they would call back if one of the Drs in the office decided to make an exception for me. Never got a call back. Dr. Simper is retiring and won't do an RNY-DS anymore anyway and I don't want an inexperienced surgeon who wants to experiment on me anyway.

I also contacted Dr. K in CA. I submitted an inquiry on the website which included my insurance info. I got an automated email saying they would get back to me with more info within 2 days. It's been 3 days and I have not heard back from that office either. Bad sign? Just be patient? I emailed them this morning to see what's up.

My next contact is Dr. Ayoola in Texas. I have not reached out yet. He allows the patient to set up an appointment on the website but I think it is a better idea to call directly and see if they would be willing to check on my insurance before I make the trip to see him. Although, I would be glad to get a thorough evaluation from Dr. A to see why I am having all of the pain and other symptoms that have been getting gradually worse and worse. Even if insurance won't cover the revision, I still want to know what is wrong with my current surgery before it becomes an emergency situation, right? Local doctors don't know much about WLS or WL surgeons won't see me even for an evaluation because I was not originally their patient. The ones I have seen are looking for new patients not old patients with potential problems and I can't blame them, really.

Besides getting the full insurance policy agreement, what else can I do? Does anybody know of a WLS in AZ that would be willing to look at me just for evaluation (not necessarily a revision? That would save me the travel expense if insurance won't cover revision. I have had the worst luck finding post-op care in the US, unfortunately. As my symptoms keep getting worse I am getting more and more nervous that after 13 years with the RNY something is not right.

Thanks you for any advise!

 

[southernlady]

Welcome CristyA

I moved this to the revision forum.

Tagging DianaCox and Larra

 

[DianaCox]

Hi Cristy. I’m in Phoenix - I wouldn’t let anyone here touch me with a 10 foot pole. If anything went wrong with my DS, I’d go back to CA to either my original surgeon Dr. Rabkin in SF or to Keshishian in Pasadena. By Lifeflight if necessary.

Get your Evidence of Coverage from your HR Dept. Can’t tell anything without seeing it.

 

[CristyA]

I just got this email from Dr K’s office. I guess I need to cross him off my list. But it’s good new about insurance!


Your insurance has been verified and you do have coverage with Dr. Keshishian for bariatric surgery. The only thing I wanted to let you know of is that our contract with Aetna is going to end soon. We don’t anticipate being in network with them in the next month or so.

Thank you,

 

[Larra]

This news isn't as bad as it sounds. If you have coverage and there is no bariatric surgeon in-network doing the necessary procedure, you can get your insurer to pay for an out of network provider at in-network rates. You may have to fight some to accomplish this, but it's been done.
So, while he's still in-network, why not have your consult with him (you need to consult with someone regardless to help sort out what's wrong with your current surgery) and see what he recommends. And, if it's something he does, argue with your insurer that no one in-network is qualified to take care of you.

 

[CristyA]

Hi Cristy. I’m in Phoenix - I wouldn’t let anyone here touch me with a 10 foot pole. If anything went wrong with my DS, I’d go back to CA to either my original surgeon Dr. Rabkin in SF or to Keshishian in Pasadena. By Lifeflight if necessary.

Get your Evidence of Coverage from your HR Dept. Can’t tell anything without seeing it.

Does Dr. Rabkin only do out of pocket? I was told he is not in-network with any insurance. (it says that in the paperwork I got from his office)

 

[DianaCox]

Rabkin will submit and accept what your insurance pays, but you will be balance billed for the rest. But the hospital charges will most likely be in-network, andvthats the most expensive part. That’s what I did. It was a few thousand dollars, but well worth it.

 

[CristyA]

Ok, I have prepared for expenses like that. Thank you!

 

[Charris]

Hey @Christa I am in Glendale Az. I put my money on Dr. K. I WOULDN'T LET NOT ONE OF THESE DR IN AZ TOUCH ME. But they would not anyways they tell you it is impossible to revise a bypass. I Was one of the early revisions from this board. I had Dr. K. Best decision I ever made. Something must have happened that Dr. K didnt get back to you as he said. That man is so thoughtful and thorough. He only deals with his patients. He NEVER ALLOWED Another dr to see me for him when I was in the hospital over 8 times. When I was in Tbird here in AZ he called and managed my care from CA. I don't know how he stays married. When I checked. In in CA at 2am he came in. He came in to discharge me on a Sunday in Ca. I'd go with Dr.K. this man has had his work cut out for him keeping my butt alive these passed 6 years!!!

 

[CristyA]

Quick update: I found Dr. Ayoola in TX is within my insurance network so he is my first choice. I have been in touch with his office and I am waiting for them to get back to me with more info. I also got information from Dr. Rabkin. He will be my 2nd choice because I would have to pay a substantial amount out of pocket but first I'd have to convince my insurance to let me see him since he is not in the network. I am fortunate that Dr. Rabkin is still a possibility. My PCP is open to helping any way she can and that might be helpful if I need my insurance to approve the initial visit to Dr. R. I just need to be patient and see where this road takes me.

Thank you all for your helpful and supportive comments

 

[Stratusphr]

I am seeking RNY to DS revision. Aetna HMO (Phoenix)

When Bariatrics is on the list of exclusions on your policy does that generally include revision surgery or are those 2 separate things? I am working on getting the full policy document from my husband's employer but I don't have it available yet. The policy summary lists bariatrics in the exclusion list but then under that, it says: "covered when medically necessary" and includes a list of criteria for revision surgery (not virgin WLS). I called HR and Aetna but I am not confident in the information I got over the phone. (They both said they do not see any exclusions in the policy for Bariatric surgery and I would have to just meet the criteria for the procedure and get a pre-approval) Then why would the summary clearly have it listed under exclusions? I'm so confused.

I am pretty pessimistic but is it possible that it means they will look at each case individually to determine coverage for revision surgery?

One doctor's office I spoke to, Dr. Simper's office, I was told they are separate things and just because one is excluded doesn't mean the other is not covered. That office won't take me on as a patient because my original surgery (RNY) was in MX. They said they would call back if one of the Drs in the office decided to make an exception for me. Never got a call back. Dr. Simper is retiring and won't do an RNY-DS anymore anyway and I don't want an inexperienced surgeon who wants to experiment on me anyway.

I also contacted Dr. K in CA. I submitted an inquiry on the website which included my insurance info. I got an automated email saying they would get back to me with more info within 2 days. It's been 3 days and I have not heard back from that office either. Bad sign? Just be patient? I emailed them this morning to see what's up.

My next contact is Dr. Ayoola in Texas. I have not reached out yet. He allows the patient to set up an appointment on the website but I think it is a better idea to call directly and see if they would be willing to check on my insurance before I make the trip to see him. Although, I would be glad to get a thorough evaluation from Dr. A to see why I am having all of the pain and other symptoms that have been getting gradually worse and worse. Even if insurance won't cover the revision, I still want to know what is wrong with my current surgery before it becomes an emergency situation, right? Local doctors don't know much about WLS or WL surgeons won't see me even for an evaluation because I was not originally their patient. The ones I have seen are looking for new patients not old patients with potential problems and I can't blame them, really.

Besides getting the full insurance policy agreement, what else can I do? Does anybody know of a WLS in AZ that would be willing to look at me just for evaluation (not necessarily a revision? That would save me the travel expense if insurance won't cover revision. I have had the worst luck finding post-op care in the US, unfortunately. As my symptoms keep getting worse I am getting more and more nervous that after 13 years with the RNY something is not right.

Thanks you for any advise!

I have a friend who highly recommends Dr Ayoola. She had a sleeve to DS revision.

 

[southernlady]

I have a friend who highly recommends Dr Ayoola. She had a sleeve to DS revision.

That’s like the second step of a regular DS. The RNY to DS revision is on the skill level of a heart transplant. Very limited number of doctors qualified for that surgery.