How to get BCBS IL PPO to pay for DS if my BMI <50

[irishmom1972]

I'm pretty discouraged and would like some advice regarding getting my insurance to pay for DS.

I'm 43 years old, BMI is 46. I'm 301 lbs, 5'8" tall. I've never had weight loss surgery before. I don't have any of the bad co-morbid conditions (yet) either. I have fibromyalgia, migraines, acid reflux, and osteoarthritis in my knees. I'm 43 years old. Past surgeries include a lap chole in 2006, emergency laparoscopy in 2009 for an ectopic pregnancy, several rounds of IVF, and an emergency C-section in 2010. Although I've been overweight my entire life and have had short term successes with weight loss on various diets (40 lbs off here then re-gain, 35 lbs off there then regain, etc.), these last 5 years have been nothing been long stalls in weight loss at dieting attempts and very slow going progress. My body, metabolism, and hormones have dramatically changed since IVF and that emergency C-section in 2010. I fear that RNY or gastric sleeve will be extremely unsuccessful for me.

I spoke with the University of Chicago Bariatric program this morning and Dr. Vivek Prachand, a well known Bariatric Surgeon who's done many successful DS surgeries. Dr. Prachand told me flat out that although he'd be happy to evaulate me, he reserves DS for patients with BMI > 50 or with severe diabetes. He also said that it's not a hard and fast rule, but something we'd discuss at my evaluation. I then talked to his intake coordinator, and she said that she's gotten some rejections for DS for BCBS IL for patients whose BMI < 50. I called BCBS IL myself and was told the same story...that a BMD-DS is "NOT considered medically necessary for patients who have BMI < 50." So I'm really discouraged. After doing a lot of research and speaking with RNY patients, sleeve patients and DS patients, it's obvious why they're calling DS the Platinum Standard for WLS. It offers the best long term results. I was getting really excited about choosing DS as my WLS choice. Currently, I have things well underway for pre-op testing with another experienced surgeon will happily do RNY or Sleeve on me, and the only reason I'd be traveling to Dr. Prachand is for the DS. Now I'm discouraged that DS won't be covered by my insurance and that it will be rejected because my BMI is under 50.

Can anyone help here? Does anyone know how I can get around these insurance stipulations or identify anymore conditions that may qualify me or get my pre-determination approved? Or is the BMI over 50 requirement for DS rigid? I can't afford self-pay. Just really bummed. I was told on another board that DS was easily approved for others by their insurance who had BMIs of just 40. So I tend to think this is a Blue Cross Blue Shield issue. I wanted to get this surgery because want the greatest chances for success and don't want to go back for another surgery 5 years from now. who knows what insurance I'll have then or where my life will be.

 

[southernlady]

Tagging @DianaCox and @Larra for you.

BTW, my Medicare was thru BCBS TN and my pre-op BMI was 35.2. (Yes, I was a diabetic, insulin pump dependent) but I insisted on the DS for my NSAID requirement.

 

[irishmom1972]

Thanks so much, Southern Lady. First I need to prove to the Bariatric Surgeon why DS is better for me that RNY or Sleeve. I forgot about the NSAID piece. Which surgery RNY or Sleeve allows NSAIDs? I'm sure whichever surgery allows NSAIDs, that's the one that the Bariatric Centers will push for then.

 

[southernlady]

Thanks so much, Southern Lady. First I need to prove to the Bariatric Surgeon why DS is better for me that RNY or Sleeve. I forgot about the NSAID piece. Which surgery RNY or Sleeve allows NSAIDs? I'm sure whichever surgery allows NSAIDs, that's the one that the Bariatric Centers will push for then.

RNY does NOT allow for NSAIDS ever again.

And many surgeons will quote the part of the ASMBS that says NSAIDS are contraindicated for ALL bariatric patients, BUT there is also this statement on the ASMBS web site: https://asmbs.org/patients/life-after-bariatric-surgery

Q: Which medications should I avoid after weight loss surgery?
A: Your surgeon or bariatric physician can offer guidance on this topic. One clear class of medications to avoid after Roux-en-Y gastric bypass is the “Non-steroidal anti-inflammatory drugs” (NSAIDs), which can cause ulcers or stomach irritation in anyone but are especially linked to a kind of ulcer called “marginal ulcer” after gastric bypass. Marginal ulcers can bleed or perforate. Usually they are not fatal, but they can cause a lot of months or years of misery, and are a common cause of re-operation, and even (rarely) reversal of gastric bypass.

Some surgeons advise limiting the use of NSAIDs after sleeve gastrectomy and adjustable gastric banding as well. Corticosteroids (such as prednisone) can also cause ulcers and poor healing but may be necessary in some situations. Some long-acting, extended-release, or enteric coated medications may not be absorbed as well after bariatric surgery, so it is important that you work with your surgeon and primary care physician to monitor how well your medications are working. Your doctor may choose an immediate-release medication in some cases if the concern is high enough. Finally, some prescription medications can be associated with weight gain, so you and your doctor can weigh the risk of weight gain versus the benefit of that medication. There may be alternative medications in some cases with less weight gain as a side effect.

 

[irishmom1972]

That's good to know. RNY is out then, as far as me trying to convince doctors that I need DS over RNY. I live on Advil at times because of severe migraines and plantar fasciitis, and my internal medicine doctor hasn't found a good migraine medicine that controls or inhibits my mirgaines. So I'm stuck with Advil. So Advil/NSAIDs are allowed for DS?

 

[Larra]

@irishmom1972 2 points:

1. You need to get your EOC (evidence of coverage) document from your insurer and read their rules for bariatric surgery and in particular for the DS for yourself. Never trust what some random employee tells you over the phone, they don't care about this and you do. This will be a lengthy document, not just a summary. If they don't cover the DS with a bmi below 50, and some policies don't, you also need to read up on your appeals rights.

2. Whether you have insurance coverage for the DS and whether or not Dr. Prachand will do a DS on you are two completely separate issues. Even if your insurance covers it, that doesn't force him, or any other surgeon, to do any operation on you if in his professional judgment it is not indicated. So, if you have coverage and he won't do it for whatever reason, you need to find a different DS surgeon.

So get that document and we'll go from there.

And Re:NSAIDs - ok with DS or sleeve, never again with gastric bypass.

 

[irishmom1972]

Thank you so much, Larra. I just called BCBS IL, and they weren't familiar with an Explanation of Coverage (EOC). She directed me to their "Medical Policies."

This post is not allowing me to cut/paste a link. So I will just paste some verbage about DS below straight from the Blue Cross/Blue Shield's Medical Policies:

Bariatric Surgery

Number:SUR716.003

Effective Date:09-01-2015

Coverage:

NOTE: Check member’s contract for benefit coverage for bariatric surgery.

PATIENT SELECTION CRITERIA FOR COVERAGE

For a member to be considered eligible for benefit coverage of bariatric surgery to treat morbid obesity, the member must meet the following two criteria:

1. Diagnosis of morbid obesity, defined as a:

• Body mass index (BMI) equal to or greater than 40 kg/meter² (* see guidelines below for BMI calculation); OR

• BMI equal to or greater than 35kg/meters² with at least one (1) of the following clinically significant obesity-related diseases or complications that are not controlled by best practice medical management:

o Hypertension, OR

o Dyslipidemia, OR

o Diabetes mellitus, OR

o Coronary heart disease, OR

o Sleep apnea, OR

o Osteoarthritis; AND

2. Documentation from the requesting surgical program that:

• Growth is completed (generally, growth is considered completed by 18 years of age); AND

• Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components:

1. Nutrition program, which may include a very low calorie diet or a recognized

commercial diet-based weight loss program; AND

2. Behavior modification or behavioral health interventions; AND

3. Counseling and instruction on exercise and increased physical activity; AND

4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health; AND

• Patient has completed an evaluation by a master’s level or higher behavioral healthcare provider acting within the scope of their licensure under applicable state law, within the 12 months preceding the request for surgery. This evaluation should document:

1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations, AND

2. The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder, AND

3. The patient’s willingness to comply with preoperative and postoperative treatment plans.

Contraindications for surgical treatment of obesity include:

• Patients with mental handicaps that render a patient unable to understand the rules of eating and exercise and therefore make them unable to participate effectively in the post-operative treatment program (e.g., a patient with malignant hyperphagia [Prader-Willi syndrome], which combines mental retardation/intellectual disability with an uncontrollable desire for food).

• Patients with portal hypertension, an excessive hazard with laparoscopic gastric surgery.

• Women who are pregnant or lactating.

• Patients with serious medical illness in whom caloric restriction could exacerbate the illness.

Bariatric Surgery in Patients with a BMI less than 35 kg/m2

Bariatric surgery is considered experimental, investigational and/or unproven for patients with a BMI less than 35 kg/m2.

* Guidelines on how to calculate BMI :

Body Mass Index (BMI) can be calculated using pounds and inches with this equation:

BMI = [Weight (lbs) ÷ Height (in2)] x 703

Body Mass Index can also be calculated using kilograms and meters:

BMI = Weight (Kg) ÷ Height (m2)

To convert pounds to kilograms, multiply pounds by 0.45.

To convert inches to centimeters, multiply inches by 2.54.

To convert feet to meters multiple feet by 0.30.

COVERAGE STATEMENTS FOR SPECIFIC BARIATRIC SURGICAL PROCEDURES (Gastric Restrictive and Gastric Malabsorptive)

NOTE: For a member to be eligible for benefit coverage of any one of these procedures the member must meet the Patient Selection Criteria described above AND the member’s contract or certificate of coverage must allow coverage of bariatric surgery.

• Gastric bypass using a Roux-en-Y anastomosis (up to and including 150 cm) may be considered medically necessary as an open or laparoscopic surgical treatment option for patients with morbid obesity who meet the eligibility criteria for surgery.

NOTE: This policy does not address Roux-en-Y gastric bypass performed primarily for the treatment of gastric reflux even though this condition may improve following a Roux-en-Y performed for the treatment of morbid obesity.

• Adjustable gastric banding (open or laparoscopic), consisting of an external adjustable band placed high around the stomach creating a small pouch and a small stoma, may be considered medically necessary as a surgical treatment option for patients with morbid obesity who meet the eligibility criteria for surgery.

NOTE: If the original adjustable gastric banding procedure was a covered benefit, it is not necessary to request documentation for refill and maintenance procedures.

• Sleeve gastrectomy (open or laparoscopic) may be considered medically necessary as a surgical treatment option for patients with morbid obesity who meet the eligibility criteria for surgery.

• Biliopancreatic bypass (Scopinaro procedure) WITH duodenal switch (open or laparoscopic) may be considered medically necessary as a surgical treatment option for morbidly obese patients with BMI of 50 kg/m² or greater who meet the other eligibility criteria for surgery.

Gastric bypass using a Roux-en-Y anastomosis, adjustable gastric banding, sleeve gastrectomy or biliopancreatic bypass (Scopinaro procedure) with duodenal switch are considered experimental, investigational and/or unproven for the treatment of any condition other than morbid obesity, including but not limited to metabolic syndrome, gastroesophageal reflux disease and sleep apnea.

The following procedures are considered not medically necessary as a treatment of morbid obesity:

• Vertical banded gastroplasty is no longer a standard of care.

• Biliopancreatic bypass with duodenal switch is considered not medically necessary as a treatment for patients with a BMI less than 50kg/m².

The following bariatric procedures are considered experimental, investigational and/or unproven as a treatment of morbid obesity:

• Gastric bypass using a Billroth II type of anastomosis (mini-gastric bypass)

• Biliopancreatic bypass without duodenal switch

• Long-limb gastric bypass procedure (i.e., >150 cm)

• Two-stage bariatric surgery procedures (e.g., sleeve gastrectomy as initial procedure followed by biliopancreatic diversion at a later time)

• Laparoscopic gastric plication

• Endoscopic bariatric procedures, either as a primary procedure or as a revision procedure (i.e., to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches). This includes, but is not limited to:

o Insertion of the StomaphyX™ device,

o Natural Orifice Transluminal Endoscopic Surgery (NOTESTM ),

o Transoral ROSE procedure (Restorative Obesity Surgery),

o Sclerotherapy of the stoma,

o Insertion of a gastric balloon,

o Endoscopic gastroplasty, or

o Use of an endoscopically placed duodenojejunal sleeve.

MISCELLANEOUS PROCEDURE COVERAGE STATEMENTS

• Repeat/Revision of bariatric surgery: may be considered medically necessary (when specifically included as a benefit or covered service in the member’s benefit plan, summary plan description or contract) only when ALL of the following criteria are met:

o Original surgery was considered a covered benefit of the member’s current plan, AND the repeat/revision of bariatric surgery is a covered benefit of the member’s current plan; AND

o For the original procedure, patient met all the screening criteria, including BMI requirements; AND

o The patient has been compliant with a prescribed nutrition and exercise program following the original surgery; AND

o Significant complications or technical failure (e.g., break down of gastric pouch, slippage, breakage or erosion of gastric band, bowel obstruction, staple line failure, etc.) of the bariatric surgery has occurred that requires take down or revision of the original procedure that could only be addressed surgically; AND

o Patient is requesting reinstitution of an acceptable bariatric surgical modality.

• New bariatric surgery following a previous different bariatric procedure: A Roux-en-Y procedure following a previously approved vertical banded gastroplasty or laparoscopic adjustable banded gastroplasty is not eligible for coverage for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the original procedure.

• Incidental procedures during a bariatric surgery: Coverage is allowed for gallbladder removal at the time of a covered gastric bypass surgical procedure, either for documented gallbladder disease or for prophylaxis.

• Repair of a hiatal hernia at the time of bariatric surgery may be considered medically necessary for patients who have a preoperatively-diagnosed symptomatic hiatal hernia.

• Repair of a hiatal hernia that is diagnosed at the time of bariatric surgery, or repair of a preoperatively diagnosed hiatal hernia in patients who do not have indications for surgical repair, is considered not medically necessary.

Larra are you able to conclude whether my insurance will give me a hard time or not being a patient with a BMI under 50 with no co-morbids?

 

[southernlady]

@irishmom1972 Your Evidence of Coverage is available thru YOUR employer or when you are signed into YOUR policy on the BCBS IL site. It is not the general "we cover this" that is available on BCBS (any state, LOL).

If you don't have a hard copy given to you by your employer, either sign into your BCBS account and get that one or contact your HR personnel and request a copy thru them.

 

[Larra]

Yes, they are going to give you a hard time based on the above. You need to get that whole document EVIDENCE of coverage, not EXPLANATION for yourself and it should include your appeals rights, if any. And @southernlady is right, you need your specific EOC, not this general info. So get that, my guess is it will be just as bad as what you have already but you never know.

Also, start documenting everything - meaning of course save all correspondence and emails, but also document every phone conversation with name of person, job title, phone number, date, time, and summary of the conversation. You would not believe how many people get misinformation from these phone calls, make decisions based on misinformation and lose out. You are dealing with an uncaring bureaucracy. Trust no one.

 

[southernlady]

Example of the difference between a "we cover this" and YOUR EOC.
My husband had his coverage thru United Healthcare at the time we started our DS journey.
The generic UHC policy required a 6 month supervised diet (and what the insurance person at the surgeon's office told him.
His actual EOC from his employer did not mention ANY 6 month supervised diet. NONE at all. But it did require 5 years of morbid obesity.

What this meant was his employer had paid extra to "write" their own coverage requirements.

We took in HIS EOC and made them copy (we did NOT let go of our copy, LOL) the relevant parts of the policy on bariatric surgery. Their "excuse" was that "normally" UHC requires the 6 month diet. Well, we didn't fit "normally".

 

[DSRIGGS]

Have you ever had a sleep study? It would not shock me if you has sleep apnea and that would give you the comorbidity.

BTW I live in Peoria but use my wife's insurance which is BCBS of Indiana. BMI was 46 and was diabetic. Also I think my DS surgeon who made my alimentary limb too short (just had a revision to fix malnutrition) was trained by Prachant....so if you get past the insurance hurdle go in eyes wide open ask lots of questions (I will be glad to answer your questions publicly or privately)

 

[hilary1617]

For what its worth. I had DS at U. of Chicago (Dr. Alverdy) covered by a BCBS IL policy, though I met the minimum BMI requirement it was not an easy road to get coverage. The surgery went well and I am very pleased with the results. If you do end up at U of C, I'm happy to connect and share my experience - feel free to send a PM.

To Scott's comments above, it was Dr. Alverdy who prompted me to get the sleep study which revealed severe sleep apnea I had no idea was present. (In fact, I tried to talk him out of making me have the sleep study because I was such a great sleeper in my own humble opinion.) So, sleep study would be helpful and will probably be required if you progress through the program there.

You are only 25 pounds or so shy of a BMI of 50 - to me that almost seems like a rounding error; surely there can be some sort of reasoning that if you don't get DS now, you are on the path to a BMI of 50?

 

[Charris]

I'm sorry that you're going through hoops to get the Dr. To do it and insurance to pay. When I called Dr. K Office for a revision they told me I would not be approved because insurance says you have to have a bmi of at least 50. I asked them to just submit it and see what,they say. I was approved in 2 day. So don't count yourself too soon. Good luck

 

[Munchkin]

Sometimes you have to fight for YOU and what you really want. Don't give up. That's what they want you to do.

Next, you say you are 5'8". I bet you don't have to be that tall. I bet you have shrunk from carrying around all that weight. And I bet they measured you with your shoes on too. I think you need to check again. And again. If you were 5'5" your BMI would be a positively magical 50.1.

Now I know you are depressed about this and comfort eating is a habit. And if you eat, you will gain weight.

Always think about the Law of Unintended Consequences.

 

[irishmom1972]

Fabulous, fabulous ideas. Thank you so much everyone.

Munchkin, I did not share half of the stress in my life when I did the psych testing because I wanted to pass the test without them requiring stress management or therapy sessions first. The psych did note that I had anxiety....maybe I could somehow use that argument with the surgeon and insurance coupled with Hilary's suggestion that I'm on my path to a BMI of 50 anyway.

Other arguments and knowledge that I've gained from this board (thank you so much!): 1. I need the malabsorption and restriction. Since my emergency C-section in 2010, my body changed metabolically and hormonally....all dieting attempts since then have been nothing but very slow going progress and immediate stalls for long stretches. Before the C-section, although my dieting attempts resulted in short term weigh loss, I was able to lose the weight 10-40 lbs at one dieting attempt. Now I can't lose weight at all. I've heard that stalls are a big issue with VSG. 2. I have fibromyalgia and chronic migraines. I need NSAIDs. My migraines have not been controlled yet by any migraine medicine that has been prescribed. Fibromyalgia Rxs cause weight gain, so I rely on NSAIDs. Tylenol never worked for me. Therefore, RNY is out because of my reliance on NSAIDs. 4. I have acid reflux. At times, it's horrible and I have to take Pepcid or another antacid. I get reflux from dairy, acidic foods, and other foods that I least expect. Therefore it seems like VSG is out because of the reflux. 5. I'm on my way to a BMI of 50 anyway since I'm unable to lose weight on my own anymore. 6. At the last couple doctors visit, my BP was in the 130s over 80. Isn't that on my way to hypertension?

I do have a pulmonologist appointment coming up. If they do a sleep study and find that I have sleep apnea, will a co-morbid condition like that help my case for DS surgery or is the BMI of 50 the hard rule?

Thanks so much everyone. Great ideas here. Unfortunately, my husband is not supportive whatsoever. A very negative angry person. So I can't tell you how much I appreciate this. These support groups are my main source of support.