Newly considering revision and need some guidance

Yes, more intestine is bypassed with DS than with distal RNY, and also you get the benefits of normal stomach function, just with a much smaller stomach.

So get that EOC and lets see what your policy covers.
 
It sounds like what you are reading is some kind of summary of benefits and not your EOC. The EOC is about 100 pages, sometimes more, very detailed and specific. and I've never seen one that says "call us".
 
I called my insurance company today and you were all right! They will cover a revision for me and I meet the criteria!!! Depending on how they code the surgery since its a revision, I may not hve to do the whole jumping through the hoops either! I'm so excited I can't wait for my consultation!
 
@Katherine, that sounds great, but you STILL need to get your EOC. We've seen so many times were people were misinformed over the phone, sometimes told they had no coverage for whatever operation was in question when they really did have coverage, and sometimes told it was covered, only to find out months down the road that it wasn't. You will be mighty pissed off if you jump through some hoops and then find out you're not covered. Get your EOC, read it yourself. Accept no substitutes!
 
So, they emailed me the criteria for surgery, but Dr. Ayoola's office said that they require a BMI of over 50 for DS. I called the insurance ppl and they said that is not correct. However BCBS TX policy says must be over 50 BI, but mu insurance ppl say that my policy with my employer has a different criteria. I don't know what to believe. Anyone have BCBS and not have a BMI over 50 and got approved?
 
At the risk of sounding like a broken record (remember records?) get your EOC and read it yourself. There are gazillions of BCBS policies. You need YOURS, not some generic policy. Asking us over and over whether or not you are covered will never get you the answer you need.
 
Larra, thats the problem, I have asked three people from BCBS for my EOC and received two different things and the third person didn't know what an EOC was. I don't know how to tell which one is the right thing. So I guess I'll just have Dr Ayoola submit the preauth and see what happens.
 
It sounds like you have your insurance through your job. Ask your HR dept for your EOC. If the first person you speak with is clueless, speak with a manager or supervisor. And when you communicate with your insurer, if you get someone clueless again, which is likely, speak with a supervisor and keep going up the food chain until you get someone who can and will help you.
If is sad that we have to be so assertive to get basic info that we are legally entitled to, but that's reality. You will need to be a polite but squeaky wheel. Personally I would not submit for preauthorization without knowing where you stand with your policy.
 
@Katherine girlfriend NOONE CARES about you getting this surgery more than you., not even Dr. A. If it's not you he will have another patient. So you're going to have to do the work like you're the only one who cares! if @Larra & @DianaCox tell you that you need to do something get it done by any means necessary. If it's not important enough for you to follow through with then don't waste their time. These ladies do this for FREE. They can help someone who will not take No for an answer. I'm not trying to be rude but I was like you when my mom and RN was alive because I knew she would get medical people in line for me. With my terrible health since she passed I had to put on my big girl undies and advocate for myself. Good luck!
 
This is what my work policy says about bariatric surgery.


What the UT SELECT Medical Plan Covers
Obesity
Surgical treatment of morbid obesity may be a covered benefit when:

It is determined to be medically necessary; and

It satisfies the criteria established in Blue Cross and Blue Shield of Texas medical policy guidelines.
Contact Blue Cross and Blue Shield of Texas customer service for current medical necessity
determination criteria

This is the link to BCBSTX bariatric criteria. This is the EOC I believe.

http://www.medicalpolicy.hcsc.net/medicalpolicy/activePolicyPage?lid=ia2d1toe&corpEntCd=TX1
 
All I see is some kind of disclaimer. Nothing about criteria for bariatric surgery.
 
This is what it says:

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.
 
But the criteria first listed says that the following two criteria must be met for bariatric surgery, which I meet.

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.
 

Latest posts

Back
Top