My First Post

[DianaCox]

After reading the Medicaid requirements, I think you need to go to the local appointment - tell them you want bariatric surgery - let them pick. Play dumb about the DS. What you want is to be approved first for bariatric surgery - that is ONE hurdle, especially with the disabling comorbidity requirement.

THEN when you're approved for surgery (and they can't deny it), you can say - oh, I've decided I want a DS, which is a standard of care procedure - and you don't have a local surgeon who can do the DS, so now I want an out-of-network referral to Dr. K or Dr. R. THEN they will say no, but we can likely help you at that point - but we need to see what their procedure will be.

 

[DianaCox]

I can't tell for sure - that's why you need the EoC - but I don't see anything in the Medicaid coverage that limits it to any specific procedures. In the next section discussing bariatric surgery generally, it says:

Today, the most commonly used bariatric technique is the Roux-en-Y gastric bypass (RYGB), and current use of the term "gastric bypass" typically refers to RYGB. Among bariatric procedures, gastric bypass is considered to be the gold standard. Four other main types of bariatric surgery are currently practiced: sleeve gastrectomy, vertical banded gastroplasty (VBG), adjustable silicone gastric banding (ASGB), and biliopancreatic diversion (BPD) with or without duodenal switch. All five procedures may be performed by open or laparoscopic technique.

Surgical treatment of obesity offers two main weight-loss approaches: restrictive and malabsorptive. Restrictive methods are intended to cause weight loss by restricting the amount of food that can be consumed by reducing the size of the stomach. Malabsorptive methods are intended to cause weight loss by limiting the amount of food that is absorbed from the intestines into the body. A procedure can have restrictive features, malabsorptive features, or both. The surgical approach can be open or laparoscopic. The clinical decision on which surgical procedure to use is made based on a medical assessment of the patient's unique situation.​

 

[DSRIGGS]

I can't tell for sure - that's why you need the EoC - but I don't see anything in the Medicaid coverage that limits it to any specific procedures. In the next section discussing bariatric surgery generally, it says:

Today, the most commonly used bariatric technique is the Roux-en-Y gastric bypass (RYGB), and current use of the term "gastric bypass" typically refers to RYGB. Among bariatric procedures, gastric bypass is considered to be the gold standard. Four other main types of bariatric surgery are currently practiced: sleeve gastrectomy, vertical banded gastroplasty (VBG), adjustable silicone gastric banding (ASGB), and biliopancreatic diversion (BPD) with or without duodenal switch. All five procedures may be performed by open or laparoscopic technique.

Surgical treatment of obesity offers two main weight-loss approaches: restrictive and malabsorptive. Restrictive methods are intended to cause weight loss by restricting the amount of food that can be consumed by reducing the size of the stomach. Malabsorptive methods are intended to cause weight loss by limiting the amount of food that is absorbed from the intestines into the body. A procedure can have restrictive features, malabsorptive features, or both. The surgical approach can be open or laparoscopic. The clinical decision on which surgical procedure to use is made based on a medical assessment of the patient's unique situation.​

Certainly not an insurance expert but I can't see why the DS would be listed in a Medicaid coverage document if they are going to exclude it. That looks like a positive to me.

@ShmittyInVegas I know this will be frustrating path, but you are past the biggest hurdle and that is deciding you need to improve your health and that the DS is what you need to give you a great shot at a healthy life. I can tell you that I made the decision that I wanted the DS in September of 2012 and thought I will get this puppy done over holiday break because I get basically two weeks off and won't have to miss too much work. Wrong I was. BCBS required a 6 month physician supervised diets along with all the obligatory classes and support group attendance monthly during the run up to surgery (that part was the surgeon in Peoria requirement). Long story short by time I was finally approved and scheduled it was the middle of September 2013. I am not saying this to discourage you but to let you know it is very common for this to take a long while to get to approval and a date for surgery....... But...... It is worth it and as frustrated as I was at being delayed, I hardly remember it now.

Good luck and persevere.

 

[southernlady]

Side bar:

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

Some, like Diana, get so many alerts, they no longer look. I have taken to PM'ing her to look at particular threads/posts as a PM is emailed. An alert is not (and can't be due to the software)

Tried to send Diana a PM but it looks like I don't have enough posts yet? If it takes getting the surgery in California, I'll do it.

@ShmittyInVegas to start a PM (called a conversation here), you click on the individuals name and an overlay pops up. Click "Start a Conversation" and you will be given a PM type box.

And there is no post limit to qualify for that...we have quite a few who come here JUST because they can get insurance help for WLS here and limiting that would put a roadblock in their way.

 

[aaa]

Hello @ShmittyInVegas .

 

[hilary1617]

Hello and welcome @ShmittyInVegas . Patience and persistence will get you where you need to go! Took me 18+ months, fighting denials, and crazy liquid diet for nearly a year to get approved, but it happened. Wishing you all the best!

 

[ShmittyInVegas]

18 months?!?!

 

[hilary1617]

Yes, 18 months. Seemed like forever then, but was well worth it and is but a distant memory now. I also didn't have any assistance - so I probably didn't follow the most efficient course. Larra and Diana are tremendous advocates and had I known them then, I suspect the timeline would have been much shorter...

 

[ShmittyInVegas]

Dr. K in So Cal doesn't take medicaid.

 

[Larra]

@ShmittyInVegas you are right, and I had forgotten. I'm sorry about that. Do you happen to also have Medicare? He does accept Medicare.

 

[ShmittyInVegas]

@ShmittyInVegas you are right, and I had forgotten. I'm sorry about that. Do you happen to also have Medicare? He does accept Medicare.

I only have Medicaid.

 

[ShmittyInVegas]

And it doesn't look like any of the California surgeons take medicaid either. Dr. Rabkin would take it only if they agree to pay their fees.

 

[DSRIGGS]

And it doesn't look like any of the California surgeons take medicaid either. Dr. Rabkin would take it only if they agree to pay their fees.

What about Simper (think) in Utah?

 

[ShmittyInVegas]

I'm checking with Simper. Waiting on an email reply.

 

[Larra]

You might want to start a new thread, asking if anyone knows of a ds surgeon who accepts medicare, if Dr. Simper doesn't.