Denial from Aetna of Ohio

[Fireballsmile]

Hello Fellow Victors!

I'm scheduled for RNY to DS revision with Greenbaum 8/19 (next wednesday). I received my denial letter from Aetna today and reason for denial is because "the requested procedure or service is excluded from coverage under the terms of the member's plan"

My Schedule of Benefits reads:

Morbid Obesity Surgical Expenses
Covered medical expenses include charges made by a hospital or a physician for the surgical treatment of morbid obesity of a covered person provided the expenses are incurred at an Institutes of Quality® (IOQ) facility. If the expenses are not incurred at an IOQ facility, no payment will be made under the plan. (GREENBAUM NOT IOQ, HOWEVER I WAS ASSURED THAT REPEAT PROCEDURE DOES NOT REQUIRE THIS)
Coverage includes the following expenses as long as they are incurred within a two-year period:
 One morbid obesity surgical procedure including complications directly related to the surgery;
 Pre-surgical visits;
 Related outpatient services; and
 One follow-up visit.

This two-year period begins with the date of the first morbid obesity surgical procedure, unless a multi-stage procedure is planned. Complications, other than those directly related to the surgery, will be covered under the related medical plan's covered medical expenses, subject to plan limitations and maximums.

Limitations Unless specified above, not covered under this benefit are charges incurred for:
 Morbid obesity surgical benefits for Bilio-Pancreatic Diversion surgical procedures.
 Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, food or food supplements, appetite suppressants and other medications; exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including morbid obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions; except as provided in this Schedule; and
 Services which are covered to any extent under any other part of this Plan.​

Aetna's Clinical Policy Bulletin 0157 reads:

1. Repeat Bariatric Surgery:
   
   Aetna considers removal of a gastric band medically necessary when recommended by the member's physician.
   
   Aetna considers surgery to correct complications from bariatric surgery medically necessary, such as obstruction, stricture, erosion, or band slippage.
   
   Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet any of the following medical necessity criteria:
   1. Conversion to a sleeve gastrectomy, RYGB or BPD/DS is considered medically necessary for members who have not had adequate success (defined as loss of more than 50 % of excess body weight) 2 years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   2. Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch, dilated gastrojejunal stoma, or dilation of the gastrojejunostomy anastomosis is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the dilation of the pouch or GJ anastomosis, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   3. Replacement of an adjustable band is considered medically necessary if there are complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments; or
   4. Conversion from an adjustable band to a sleeve gastrectomy, RYGB or BPD/DS is considered medically necessary for members who have been compliant with a prescribed nutrition and exercise program following the band procedure, and there are complications that cannot be corrected with band manipulation, adjustments or replacement.

I guess my question is, would, should, could the CPB supersede (or could I argue it) that the BPD/DS is a medically necessary surgery for REPEAT procedure according to their own Bulletin; and is the angle you would take @Larra or @DianaCox ?

My highest recorded BMI was a smidge under 40 and I don't have any officially diagnosed co-morbidities, though this doesn't appear to be the issue with the denial.

If it is a realistic argument that the DS ought to be covered, I will try, I just need a little encouragement that it's not a lost cause.

Thank you eternally for your time, input and dedication to everyone
Nickie

 

[DianaCox]

You need to IMMEDIATELY contact the insurance company and force them to put in writing which reason they used for denial - is it for Greenbaum not being in their network? Is it because you didn't meet the preop requirements you think didn't apply to you? (Do you have anything in writing that supports your belief that neither of these requirements would apply to you because it's a revision?) The ONLY easy to overcome issue would be if they mistakenly assumed you were having a BPD instead of a DS (if Greenbaum is one of the dinosaurs who keeps insisting on using the BPD/DS nomenclature). CALL NOW!!

 

[Fireballsmile]

Thank you Diana, I can scan the denial letter and send it, but the only verbiage that pertains to the reason is that the requested procedure or service is excluded.

The Procedure code that must have been submitted is 43845 with the description included on denial latter: - GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS-PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100CM COMMON CHANNELL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH)

I'm sorry, is my priority to call Greenbaum's office or insurance to clarify the procedure?
TYTYTYTY
Nickie

 

[Fireballsmile]

And one more thing, @DianaCox should Tina just have submitted a different procedure code or is the DS not truly a Bilio-Pancreatic Diversion procedure?
thank you

 

[DianaCox]

43845 is the correct CPT code for the DS. That doesn't mean the nimrod at Aetna didn't deliberately misunderstand it. Insurance companies often deliberately deny bariatric surgeries (and other procedures they don't want to pay for) for reasons that are phony, hoping that the patient will simply give up and not appeal (and they are probably correct 90+% of the time). Because they can.

Call Aetna and demand clarification of the basis for denial. Demand to speak to a supervisor, and to get the answer IN WRITING ASAP.

Not sure whether you'd want to risk this, but having received a denial, your right to appeal is vested - if you can (1) afford to cash pay, and (2) afford to NOT eventually get reimbursed, you can go ahead with surgery next week and appeal afterwards.

 

[Larra]

I'm confused as to the justification for the denial, but as @DianaCox so accurately says, they often issue denials just because they can. It seems like your policy has much better coverage for revisions than many we've seen. I agree with Diana - insist on a specific reason for the denial and we can go from there. Go up the food chain until you get to someone who can answer this question, and document everything, including the name and job title of this person, date, time, phone number, and summary of the conversation.

 

[Charris]

welcome you are definitely in the right place to get help regarding insurance issues. It doesn't get any better that having Larra and Diana helping to sort out you insurances regarding WLS

 

[Fireballsmile]

Thank you so much ladies. @DianaCox, the information you provided that my right to appeal is vested, is huge! That's a relief and is exactly what I will do then; appeal, pay out of pocket and then square up with Aetna after the surgery... hopefully! My phone call went as I expected. They claim that the denial letter has everything in writing that applies. The plan doesn't cover it - period. I initiated the appeal process arguing that what my plan doesn't cover, ISN't the DS.

@Larra it's the Clinical Policy Bulletin (CPB) that Aetna uses to complement plans that aren't explicit in their coverage along side them, that is so favorable toward "Repeat Procedures". My own personal plan says ZILCH about it. The only thing that my plan states explicitly is that it covers any bariatric procedure occurring in an IOQ facility - EXCEPT Biliopancreatic Diversion Surgery procedures. Phrased like this:

Limitations Unless specified above, not covered under this benefit are charges incurred for:
* Morbid obesity surgical benefits for Bilio-Pancreatic Diversion surgical procedures.​

I was told early on by an aetna concierge nurse that the IOQ distinction was not necessary for repeat procedures based on that CPB - but do you think I got it in writing? No. So, when the denial came and it was only that the procedure I'm getting isn't covered, I was at least relieved about that. Not to say they won't use that later.

This phrasing worries me because isn't the DS technically a bilio-pancreatic diversion "type" procedure? I know that it isn't the BPD, but the procedure code itself describes it as the biliopancreatic diversion with duodenal switch. They'll have me on that, I'm sure.

You ladies really do perform magic here. It's widely appreciated, but if only we all could see you amidst the cruise ship-load of people all in one place who's life you've impacted and helped to better. You'd be surrounded by a world of love and hugs.
Nickie

 

[DianaCox]

Biliopancreatic diversion (AKA, the Scopinaro procedure) is assigned CPT code 43847, which is completely distinct from the DS (CPT 43845).

http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/surgery_for_morbid_obesity.pdf

1. Biliopancreatic Bypass Procedure (also known as the Scopinaro procedure) (CPT code 43847). Biliopancreatic bypass (BPB) procedure, developed and used extensively in Italy, was designed to address some of the drawbacks of the original jejuno-ileal bypass procedures that have been abandoned due to unacceptable metabolic complications. Many of the complications were thought to be related to bacterial overgrowth and toxin production in the blind, bypassed segment. In contrast, BPB consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-enY procedure. The procedure consists of the following components.

1. A distal gastrectomy functions to induce a temporary early satiety and/or the dumping syndrome in the early postoperative period, both of which limit food intake.
2. A 200-cm long “alimentary tract” consists of 200 cm of ileum connecting the stomach to a common distal segment.
3. A 300- to 400-cm “biliary tract,” which connects the duodenum, jejunum, and remaining ileum to the common distal segment.
4. A 50- to 100-cm “common tract,” where food from the alimentary tract mixes with biliopancreatic juices from the biliary tract.​

Food digestion and absorption, particularly of fats and starches, are therefore limited to this small segment of bowel, i.e., creating a selective malabsorption. The length of the common segment will influence the degree of malabsorption. 5. Because of the high incidence of cholelithiasis associated with the procedure, patients typically undergo an associated cholecystectomy. Many potential metabolic complications are related to biliopancreatic bypass, including most prominently iron deficiency anemia, protein malnutrition, hypocalcemia, and bone demineralization. Protein malnutrition may require treatment with total parenteral nutrition.​

In contrast:

2. Biliopancreatic Bypass with Duodenal Switch (CPT code 43845), which specifically identifies the duodenal switch procedure, was introduced in 2005. The duodenal switch procedure is essentially a variant of the biliopancreatic bypass described here. In this procedure, instead of performing a distal gastrectomy, a “sleeve” gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum, similar to the biliopancreatic bypass, to create the alimentary limb. Preservation of the pyloric sphincter is intended to ameliorate the dumping syndrome and decrease the incidence of ulcers at the duodenoileal anastomosis by providing a more physiologic transfer of stomach contents to the duodenum. The sleeve gastrectomy also decreases the volume of the stomach and decreases the parietal cell mass. However, the basic principle of the procedure is similar to that of the biliopancreatic bypass; i.e., producing selective malabsorption by limiting the food digestion and absorption to a short common ileal segment.​

NOTE ALSO: This version of Aetna's CPB-0157 (http://www.aetna.com/cpb/medical/data/100_199/0157.html) says that both the BPD with AND without the DS are standard of care procedures:

"Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic sleeve gastrectomy, open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met."
​

Let's see them get around THAT!

 

[DianaCox]

Here's another piece of ammo: http://asmbs.org/resources/systematic-review-on-reoperative - the ASMBS endorses the DS as a reoperative surgery for RNY.

Treatment of acute and chronic complications after bariatric surgery
RYGB
Conversion. Indications for conversion of RYGB to another procedure are primarily related to weight regain or recurrence of co-morbid disease, but rare metabolic derangements of the primary operation (refractory neuroglycopenia, recalcitrant hypocalcemia with associated hypoparathyroidism, and severe malnutrition) may require conversion of RYGB to SG or BPD/DS, or original anatomy [86], [87]. These reports demonstrate technical feasibility and short-term results of these 1- or 2-stage conversion procedures.

****

1. Morbid obesity is a chronic disease and acceptable long-term management after a primary bariatric procedure should include the surgical options of conversion, correction, or other adjuvant therapy to achieve an acceptable treatment effect in cases of weight recidivism, inadequate weight loss, inadequate co-morbidity reduction, or complications from the primary procedure.
2. “One bariatric procedure per lifetime” and other coverage policies that limit or prohibit reoperative bariatric surgery are not consistent with coverage policies provided for any other chronic disease process, and should be abandoned where they exist.

 

[aaa]

Gotta love this site.

 

[Fireballsmile]

Oh, I do @aaa , I do!
@DianaCox thanks so much for that verbiage. Keeping it in my pocket for sure.
Sadly, I informed Greenbaum's office that I will pay out of pocket and somehow amazingly the price quoted to me in the beginning for the full price of the procedure DRASTICALLY increased! My hospital stay alone now will be $18,574.00. Which I know very well is peanuts for Dr Keshishian, but for Greenbaum, this is extremely high and much higher than the "estimate" that I was given originally and higher than I know I've seen several other patients on this site paid.
So I'm bummed as this is the reason I opted for Greenbaum's office to begin with.
Dr. G's fees are only $3,649 and Anesthesia was $1,500 more.

I have 5 days to do some soul searching and see if biting the bullet is a risk I want to take right now; waiting out for possible insurance reimbursement.

Thank you again
Nickie

 

[Larra]

@Fireballsmile the lower price may have been for a virgin DS - I'm not sure. I'm sorry the price, at least for you, has gone up. Dr. G's fee and the anesthesia fee sound very reasonable. I hope this will work out for you.

 

[Settledownnow]

@Fireballsmile
that is much higher than the self-pay price for revision that I was quoted a couple of weeks ago. I was told approx $11,800 for surgery, anesthesia and hospital room. I was quoted 850.00 per day for any extra days in the hospital. You might check again for the "self-pay" price!!!

 

[Fireballsmile]

@Settledownnow and fyi to @Larra and @DianaCox
This last two days has been a journey in itself. Virtua Memorial HAS raised their hospital fees and it appears that I'm either the first patient to be charged the new fees, OR, would have been the last patient, to receive the old fee structure.
I too was estimated that same price, Jan, but they're finally getting more in line with national averages I guess. Even me as novice can understand that 11,000 for a complex surgery with one of the nations best surgical teams and a 4-5 day hospital stay is barely enough to truly cover the expenses. I was devastated to get the final quoted price, but it too is still competitive when you consider all the other costs by the vetted revision surgeon's list. I may have to postpone to save up a few more dollars, or to at least wait for my insurance appeal answer which with come 8/26.

What Virtua did permit on the intervention of Dr G and Tina, the office coordinator, was to accept 1/2 payment up front and payment plan for the remaining. This is what I have been soul searching about. My husband and I do not want to put this on credit and so I just have to decide within the next two days if we want to take that kind of risk.

Now hows this for a mind *bleep*--- I'm 11 days into a treacherous liquid protein fast and I may be postponing my surgery... I walked around yesterday totally aimless. Afraid to eat, but no solid motivation to keep myself hungry! It was a real trip. Considering starting over in a few weeks/months when I'm this close was very depressing to say the least. I must believe that I'll go through with it to get through this weekend and feeding my kids and so forth and then Monday give the final answer to Tina. Flights, hotel room, transportation and care for myself and the kids while I'm away... well that's all in the balance too.

I will keep you posted.
Nickie