My First Post

[Larra]

Hi and welcome!

The key is going to be what your policy covers. From what you've said so far it sounds like your coverage is provided their the state of Nevada in some way. You need to get a copy of your EOC (evidence of coverage) either on paper or online. This is a lengthy document not just a summary of benefits, and it will tell you whether or not the DS is covered, and also what appeals rights, if any, you have.
there is definitely no DS surgeon in Nevada. However, IF your policy covers the DS and IF you are not strictly limited to medical care in Nevada, you are not too far from Dr. Keshishian in Glendale (a suburb of Los Angeles), and he's one of the best for the DS. So the key is knowing more about your coverage.
I agree with everyone else that the DS is far and away your best choice. It has the best statistics of any bariatric surgery for percentage excess weight loss, for maintaining that weight loss, and for resolution of almost all comorbidities, including sleep apnea and high blood pressure. Maintenance of weight loss is a big problem with gastric bypass and other operations. Many people do well initially, only to find themselves struggling a few years later. Also, while the DS works well for the "lightweights" of the bariatric surgery world, it is esp useful for people with higher bmi's.
All in all, if you can find a way to have it covered by your insurance, the DS is the way to go, so get your EOC. People here will gladly help you but without knowing what your policy covers, we are just lost little Easter eggs, just like you.

 

[Clematis]

If you put someone's screen name in your post immediately proceeded by a @ sign, like this @ShmittyInVegas they will get an alert.

 

[ShmittyInVegas]

Hi and welcome!

The key is going to be what your policy covers. From what you've said so far it sounds like your coverage is provided their the state of Nevada in some way. You need to get a copy of your EOC (evidence of coverage) either on paper or online. This is a lengthy document not just a summary of benefits, and it will tell you whether or not the DS is covered, and also what appeals rights, if any, you have.
there is definitely no DS surgeon in Nevada. However, IF your policy covers the DS and IF you are not strictly limited to medical care in Nevada, you are not too far from Dr. Keshishian in Glendale (a suburb of Los Angeles), and he's one of the best for the DS. So the key is knowing more about your coverage.
I agree with everyone else that the DS is far and away your best choice. It has the best statistics of any bariatric surgery for percentage excess weight loss, for maintaining that weight loss, and for resolution of almost all comorbidities, including sleep apnea and high blood pressure. Maintenance of weight loss is a big problem with gastric bypass and other operations. Many people do well initially, only to find themselves struggling a few years later. Also, while the DS works well for the "lightweights" of the bariatric surgery world, it is esp useful for people with higher bmi's.
All in all, if you can find a way to have it covered by your insurance, the DS is the way to go, so get your EOC. People here will gladly help you but without knowing what your policy covers, we are just lost little Easter eggs, just like you.

I have a PDF (tried to paste it but it won't link to my post), it is at the top of this google search "Health Plan of Nevada duodenal switch." It shows that it is "medically necessary" in their Commercial, Federal Employee and Medicare, but it doesn't list the proceedures under Medicaid like it does with the other coverages? Google: "Health Plan of Nevada duodenal switch" and the PDF is the top result.

 

[DianaCox]

On page 3/32 in that document, it says:

BENEFIT CONSIDERATIONS

Many Evidence of Coverage (EOCs) explicitly exclude benefit coverage for bariatric surgery.

Several states mandate coverage for bariatric surgery. Please refer to the enrollee-specific benefit document to determine availability of benefits for these procedures. As in all benefit adjudication, state legislated mandates must be followed. Therefore, the applicable state-specific requirements and the enrollee-specific benefit document must be reviewed to determine what benefits, if any, exist for bariatric surgery.

Laparoscopic and "open" obesity surgeries are different and distinct procedures, from the standpoint of administering in network and out of network benefits. Similarly, biliopancreatic diversion with duodenal switch is a unique procedure from the standpoint of administering in network and out of network benefits.​

You need to figure out what benefits are associated with YOUR policy!

 

[ShmittyInVegas]

On page 3/32 in that document, it says:

BENEFIT CONSIDERATIONS

Many Evidence of Coverage (EOCs) explicitly exclude benefit coverage for bariatric surgery.

Several states mandate coverage for bariatric surgery. Please refer to the enrollee-specific benefit document to determine availability of benefits for these procedures. As in all benefit adjudication, state legislated mandates must be followed. Therefore, the applicable state-specific requirements and the enrollee-specific benefit document must be reviewed to determine what benefits, if any, exist for bariatric surgery.

Laparoscopic and "open" obesity surgeries are different and distinct procedures, from the standpoint of administering in network and out of network benefits. Similarly, biliopancreatic diversion with duodenal switch is a unique procedure from the standpoint of administering in network and out of network benefits.​

You need to figure out what benefits are associated with YOUR policy!

And these are all available on the web? (I'm new to insurance, being that this is my first coverage since college!)

 

[DianaCox]

Probably not - you may have to demand a copy of the EoCs from the insurance companies offering them.

Here is the document referenced above.

 

[ShmittyInVegas]

I found the Health Plan of Nevada EOC online and it shows that "gastric restrictive surgical services" are covered but it doesn't mention any specific procedure, just the criteria for coverage? Looking for the Amerigroup EOC.

 

[DianaCox]

I don't quite understand this - the bariatric policy says that your insurance considers the DS to be a standard of care procedure - but YOUR plan may not cover it. You need to find out whether YOUR plan would cover it!

 

[ShmittyInVegas]

I don't quite understand this - the bariatric policy says that your insurance considers the DS to be a standard of care procedure - but YOUR plan may not cover it. You need to find out whether YOUR plan would cover it!

I'll call them tomorrow. Will they answer these types of questions over the phone or do I have to wait for them to mail me an EOC?

 

[DianaCox]

Ask them to EMAIL a pdf of the EoC, as well as YOUR specific bariatric policy.

 

[Munchkin]

Welcome! I live in Vegas too. Diana and Larra are the insurance experts. They have forgotten more than most of us will ever know. I also urge you to actually get a copy of your real policy. Read, re-read, and get to know your new best friend. Then just buckle up and go on the ride. This takes time and there is nothing easy about it. You will be denied over and over and they hope you will just give up and go away. This is a game they play with your life and you have to be more persistent than they can be resistant.

Yes I know that once you finally make that big decision, you want to get it done yesterday. That won't happen.

Just my opinion but I don't think there are any great bariatric surgeons here. Sorry! And there is not a one among all these also-rans who does the DS. I also believe your best bet is Cali. After all, it's just down the road.

 

[ShmittyInVegas]

Sounds like I need to make a detailed "To Do List" to get the DS procedure in Cali. Oh, I will be persistant, for sure. I just need to make a list of what I need to do, and what to expect (much of which seems to have been covered here).

 

[ShmittyInVegas]

If I am going to be seeking the DS, should I keep my initial appointment with my local surgeon or just meet with my PCP and have her refer me to a Cali surgeon who performs the DS?

 

[DianaCox]

OK, I looked more carefully at the document and found this, starting on page 8:


MEDICAID COVERAGE RATIONALE

Medicaid coverage reviewed May 2015. Pg.317. BMI requirement lowered from 40 or greater to 35 or greater.

Medicaid coverage updated May 2015. Effective February 1, 2015, Medicaid updated their diet requirement from three years to three months prior to planned surgery.

Bariatric Surgery is a covered Nevada Medicaid benefit reserved for recipients with severe and resistant morbid obesity in whom efforts at medically supervised weight reduction therapy have failed and who are disabled from the complications of obesity. Morbid obesity is defined by Nevada Medicaid as those recipients whose Body Mass Index (BMI) is 35 or greater, and who have significant disabling comorbidity conditions which are the result of the obesity or are aggravated by the obesity. Assessment of obesity includes BMI, waist circumference, and recipient risk factors, including family history.

This benefit includes the initial work-up, the surgical procedure and routine post surgical follow-up care. The surgical procedure is indicated for recipients between the ages of 21 and 55 years with morbid obesity. (Potential candidates older than age 55 will be reviewed on a case by case basis.)

Prior Authorization is required.

Documentation supporting the reasonableness and necessity of bariatric surgery must be in the recipient’s record and submitted with the prior authorization.

Coverage is restricted to recipients with the following indicators:

1. BMI 35 or greater; and
2. Waist circumference of more than 40 inches in men, and more than 35 inches in women; and
3. Obesity related comorbidities that are disabling; and
4. Strong desire for substantial weight loss; and
5. Be well informed and motivated; and
6. Commitment to a lifestyle change; and
7. Negative history of significant psychopathology that contraindicates this surgical procedure.​

Documentation supporting the reasonableness and necessity of the surgery must be in the medical record, and should include evidence of participation in a medically supervised weight loss program for a minimum of three months prior to the surgery. There must also be documentation of weight loss therapy participation including recipient efforts at dietary therapy, physical activity, behavior therapy, pharmacotherapy, combined therapy, or any other medically supervised therapy.

 

[ShmittyInVegas]

OK, I looked more carefully at the document and found this, starting on page 8:


MEDICAID COVERAGE RATIONALE

Medicaid coverage reviewed May 2015. Pg.317. BMI requirement lowered from 40 or greater to 35 or greater.

Medicaid coverage updated May 2015. Effective February 1, 2015, Medicaid updated their diet requirement from three years to three months prior to planned surgery.

Bariatric Surgery is a covered Nevada Medicaid benefit reserved for recipients with severe and resistant morbid obesity in whom efforts at medically supervised weight reduction therapy have failed and who are disabled from the complications of obesity. Morbid obesity is defined by Nevada Medicaid as those recipients whose Body Mass Index (BMI) is 35 or greater, and who have significant disabling comorbidity conditions which are the result of the obesity or are aggravated by the obesity. Assessment of obesity includes BMI, waist circumference, and recipient risk factors, including family history.

This benefit includes the initial work-up, the surgical procedure and routine post surgical follow-up care. The surgical procedure is indicated for recipients between the ages of 21 and 55 years with morbid obesity. (Potential candidates older than age 55 will be reviewed on a case by case basis.)

Prior Authorization is required.

Documentation supporting the reasonableness and necessity of bariatric surgery must be in the recipient’s record and submitted with the prior authorization.

Coverage is restricted to recipients with the following indicators:

1. BMI 35 or greater; and
2. Waist circumference of more than 40 inches in men, and more than 35 inches in women; and
3. Obesity related comorbidities that are disabling; and
4. Strong desire for substantial weight loss; and
5. Be well informed and motivated; and
6. Commitment to a lifestyle change; and
7. Negative history of significant psychopathology that contraindicates this surgical procedure.​

Documentation supporting the reasonableness and necessity of the surgery must be in the medical record, and should include evidence of participation in a medically supervised weight loss program for a minimum of three months prior to the surgery. There must also be documentation of weight loss therapy participation including recipient efforts at dietary therapy, physical activity, behavior therapy, pharmacotherapy, combined therapy, or any other medically supervised therapy.

I've read that (thought I didn't think that was the EOC?). It states that criteria (which I should meet). But in the medicaid section it doesn't mention the proceedures like they did in the Commercial, Federal Employee and Medicare Rationale?