Insurance advice needed for my goal to have gastric bypass revision to DS

Sparkles1979

Revision wanted from RNY to DS
MY STORY

I had an RNY in 2001, lost 160 pounds, and kept it off for about 11 years. I originally had my surgery at Pacific Bariatrics in San Diego with Dr Zorn and went through my parents insurance. I think it was BC? I gained 100lbs 7years ago when I got pregnant with my only child and I had preeclampsia. I've tried on and off extreme dieting plus working out and I never was able to take off a lot of weight. I got up to 245 recently but I have since lost 25 lbs in the last few months by using shakes and limiting consumption to 1000-1200 calls but it’s going so slow and I feel desperate. I’d love to get the DS but apparently I need to be 40 BMI and I’m 37. I don’t think I have any comorbidities. I have struggled with Anemia, but i’m wondering if that is because of scar tissue - In 2010 or 2011 I had a partial blockage of my intestine and they had to “unwind” my intestinal track because it got twisted.

I currently have Kaiser and am looking into getting Anthem Blue Cross PPO through my husband's work but to insure the three of us would be $850 a month and we can't afford it. Our other option would be to get double insured (my husband and I get Anthem BC through his work and then my daughter and I get Kaiser through my work which in all would be $400 monthly - still difficult but doable), but I'm afraid that somehow being covered under Kaiser would somehow make me have difficulties being insured under BC. I’m trying to be strategic in figuring out steps to set me up for a good chance to be approved. I've also been going to the Kaiser Bariatric support group for 2 months. I don't know if this helps me insurance wise.

So my questions are:

  1. Should I get double insured or could this cause issues with my BC kicking in
  2. Has anyone had issues with getting insured under a BMI of 40 for a revision
  3. After begging, Kaiser has set up a Barium Swallow for me...is this a good test to detect if there are issues? Can I use this test results even when I switch over to BC?
  4. Once I get the insurance what is the best order of things. Do I go directly to the Bariatric Surgeon (I think I want Dr. Keshishian), or should I set myself up with a PCP first?
Any advice would be greatly appreciated. I know the order of things matter and I want to be careful in how I handle things.

DianaCox and Larra for visibility.

Thank you in advance!
Christine
 

CristyA

Member
Hi, I’m in the same boat. At 38-9 BMI. Had RNY in 2006. Had a baby 8 years after surgery and started gaining weight after baby because I started having hypoglycemia during pregnancy which caused me to eat more then I was used to. After giving birth I continued to experience hypoglycemia.

Anyway, I’m scheduled to get my pre-op tests done. My surgeon’s office said my insurance requires some proof that the surgery failed and needs to be revised so that’s what they are looking for with the tests. I believe that is what the upper endoscopy they scheduled is for and the sleep study to see if I have sleep apnea (which is definitely possible). He didn’t seem concerned with the fact that my BMI is under 40 or that I haven’t developed or been diagnosed with co-morbidities.

Good luck in getting approved! I am also concerned that I might get denied because of the BMI and lack of co-morbidities but I’m still hopeful that the Dr can find enough evidence to get me approved.
 

Sparkles1979

Revision wanted from RNY to DS
Oh my...hi there bariatric sister! I had preeclampsia and really swelled up those final months. I gave birth two months early so that weight gain at the end was surprising as massive. Did you get referred to the doc by your pcp or did you go directly. Good luck!
 

CristyA

Member
Oh my...hi there bariatric sister! I had preeclampsia and really swelled up those final months. I gave birth two months early so that weight gain at the end was surprising as massive. Did you get referred to the doc by your pcp or did you go directly. Good luck!
My insurance allows me to see any specialist as long as they are in network so I just started searching for a qualified surgeon. I found 3 and started calling/emailing to get more information and I finally settled on Dr Ayoola in TX.
 

DianaCox

Bad Cop
I’m not sure how having two insurances works - I’m on Medicare now, but when I had employer provided insurance, every year they would ask me to disclose any other insurance I had do they could apply “coordination of benefits” - which probably means you don’t get any better benefits than if you only have one.

The qualification for revisions due to complications is different from revisions due to inadequate weight loss. But if you still qualify for ANY bariatric surgery, especially if you’re in CA, DS is an option. But Kaiser will make your approval very complicated.
 

southernlady

Administrator
Staff member
Actually having 2 insurance companies means your copay ends up being lower depending on who is primary and who is secondary.
Okay, from 2002 to 2011, I had Medicare as secondary. It would be submitted to my primary, they paid their portion. Then submitted to Medicare who paid 80% of what my primary did not pay. Example: primary pays all but $100. Without Medicare, I would have paid $100. But with Medicare as my secondary, they paid $80 of that $100. That left me with only $20 to pay.

Then we flip flopped and Medicare was primary (for about one year). Medicare paid 80% and my secondary paid their portion. My part usually would be about $80. of that same $100 example.

Now I am on just Medicare due to stupidity on my Humana Advantage plan. I’m in a two month gap before my Supplement kicks in. I chose the F plan which will not be available in 2020 for new enrollees. I will have no copay with most the medical I receive.

Confused yet?
 

Sparkles1979

Revision wanted from RNY to DS
Hi Ladies, For some reason I didn't see your responses! I must have not set my alerts correctly.

So the Barium Swallow showed nothing out of the ordinary according to my Kaiser doctor. Its also looking like I may not be able to get the Anthem Blue Cross. Is there any way to get Kaiser to pay for my DS surgery with Dr. Keshishian when they wont do an endoscopy and the barium swallow is clear. I already know the answer but I just wanted to make sure I exhausted all issues.

I have never met a surgeon at Kaiser. They only have me talking to the bariatric nurse and my PCP. Maybe because I never had gastric bypass with them to begin with, so I was never assigned a surgeon. It just seems like I'm getting 2nd hand info.
 

DianaCox

Bad Cop
I think the next step is to request/demand an appointment with Dr. Belzberg at Kaiser (you’re in SoCal, right?).
 
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