BCBSIL denial revision vsg to DS

[KZ2NDCH]

Hello everyone! Had VSG in 2015 and was marginally successful (60lbs 45-50 short of goal). Got pregnant in 2016 and gained almost all the weight back. After pregnancy never felt the restriction again. Was seeking revision to RNY but was denied by bcbsil for non-compliance. Then did 3 month diet. Surgeon resubmitted for SIPS, which is the one he recommended but was denied do to BMI not at 50. I am 45-47. Was supposed to have a peer to peer Friday but heard from assistant and she said it was a short talk and dr recommends I do a specialty appeal. I fear it won’t be approved, I consulted a lawyer and they said insurance can be strict about BMI requirement.

Is there a way to win appeal? Is there a difference between revision and conversion requirement? Can they use my initial BMI when I first started WLS journey?

I really want sips and not rny for long term success and want to fight it. But don’t want to waste money on a lawyer to then still get denied.

Anyone have success with bcbsil approval without meeting BMI requirement?

 

[Webmommy]

Have you done any reading on the difference between SIPs and the standard DS? There hasn't been any long term studies that support the successful weightloss unlike the DS. so is there a particular reason why you're determined to do this one? Also, SIPs is experimental and unlikely to be approved with even the best negotiation. I highly encourage you to consider seeing someone who does the traditional DS by a vetted surgeon here who actually does the surgery.

 

[KZ2NDCH]

Mainly the reason is my surgeon does not do DS only SIPS. Some places I have read they require BMI of 60. My surgeon also stated not as complicated as ds and has reduced amount of side effects as opposed to full ds.

It is an option though going to some in Chicago, which is a little far from me, I am in northern Illinois. However, I feel I would be starting the process all over. I have already spent thousands doing all the required labs, psych evaluation, supervised diet,endoscopy, exercise specialist. I am nervous to get declined by surgeon for ds.

 

[Spiky Bugger]

Hi. Welcome. And, what Webmommy said.

I’m just guessing here, but I’ve been reading on this topic for well over 15 years, so here I go:

Your surgeon is recommending SIPS, not because it the best surgery for you, but because he knows a revision from VSG to DS is the best route to take and he has no experience with the real DS.

So, the good news:
You’re fighting with BCBSIL about compliance nonsense. That means you don't have a “once you’ve had ANY bariatric surgery, anywhere, paid for by anyone, you don’t get a second procedure” clause in your policy. (Some people do.)

And the IMHO bad news:
It sounds like you’re fighting to get a surgery that even the Association of Metabolic and Bariatric Surgeons does NOT include on its list of bariatric surgeries and which has no long term results available.
https://asmbs.org/patients/bariatric-surgery-procedures

You may really like your surgeon. You may really want to stay close to home. But you also might want to back up a bit and take a look at what you can do to make sure this is your LAST bariatric surgery.

Sue

 

[Spiky Bugger]

We were posting at the same time, but “far” is a relative term.

We’ve known patients who went from Alaska to Brazil and from Washington State to Spain to get the real DS.

 

[KZ2NDCH]

Very valid points. I might need to look into surgeons who do the full ds in illinois.

Can anyone recommend any in Illinois that would accept you with a BMI less than 50?

 

[southernlady]

Welcome KZ2NDCH

Very valid points. I might need to look into surgeons who do the full ds in illinois.

Can anyone recommend any in Illinois that would accept you with a BMI less than 50?

I would look for a DS surgeon regardless of what state. Best options are:
Dr. K in CA
Dr. Rankin in CA
Dr. Ayoola In TX
Dr. Boyce in TN
Dr. Inman in IN
Dr. Sudan in NC
Dr. Simper in Utah (his partner mostly now, since we’ve gotten word that Simper is retiring) STAY AWAY FROM COTTAM IN UTAH.
Dr. Dakin in NYC (Pomp is retiring).
Dr. Smith in Celebration, FL.
There is one in WA, but can only remember the first letter of his name.

There are a few more and any DS surgeon can handle the revision from VSG to DS but make sure they actually do the DS.

A vast majority of DSers are not lucky enough to live near a true DS surgeon. Even one within a day’s drive. Be prepared to travel.

 

[Sheanie]

Paul Kemmeter is in Grand Rapids, Michigan. He does the true DS, and he is a really nice guy. He satellites in Traverse City, as well.

 

[southernlady]

Paul Kemmeter is in Grand Rapids, Michigan. He does the true DS, and he is a really nice guy. He satellites in Traverse City, as well.

Forgot him when putting all the ones I remembered. Thanks for reminding me and getting his name here.

 

[Larra]

In Washington State it's Dr. Srikanth.

 

[RainCity]

• Dr. Ara Keshishian (aka Dr. K) is in Pasadena, CA (Los Angeles suburb)
• Dr. John Rabkin is in San Francisco, CA
• Dr. Myur Srikanth is in Federal Way, WA (Seattle suburb)

 

[KZ2NDCH]

Thank you everyone for the suggestions. Has anyone had luck with one of these surgeons approving less than 50bmi?

 

[DianaCox]

The surgeon isn’t usually the problem - it’s the insurance.

 

[Sheanie]

My BMI was quite a bit less than 50. I had BCBS of Michigan, and needed no comorbidities. But that was 2009, before insurances got really bad about DS approval. I was approved in a month.

Diana is right. Its your insurance that is the hurdle. The surgeons office knows how to get it approved, but if your insurance is being stinky, you're in for a battle.

If I couldnt get it approved, I would save up and self pay. Many have done this.

 

[southernlady]

I had BCBS TN Medicare with a BMI of 35.2 but with diabetes, high cholesterol and other comorbids. Had absolutely no problem getting approval for the DS. I’m not sure if BCBS TN would have approved but the Medicare part overrode the BCBS half.