Peer-to-peer review denied for DS approved for VSG & self pay DS: Advice please!

[writegirl]

So, my surgeon conducted the peer-to-peer review today with BCBS State of TN. As expected, they again denied my DS because I do not meet their criteria of being at a 60 BMI. While they denied me, they did give me options: Appeal; or Select another procedure (Rny or VSG) and they will approve; or select the BPD-DS and they *will* pay for the entire VSG part of the procedure if I self pay an additional $3000.00 for the BPD part.

The patient advocate said that she "wouldn't recommend appealing" if I want to have surgery this summer because the BMI requirement is "part of their policy" and since I agreed to purchase that policy, they will likely deny me again.

I'm not sure what I *should* do here. Part of me is ready to jump to the third option and self pay the difference. Part of me is pissed off that the insurance company can get away with NOT covering a procedure covered everywhere else because of some arbitrary BMI number they hamstring patients with to avoid paying for this procedure.

That said, as many of you already know, I will be changing positions and possibly my employer by the start of August. I may be facing an insurance change or loss of coverage, so getting my surgery done ASAP is a priority.

Would you recommend self paying the difference? If not, what are the reasons why not. Would you recommend just getting the VSG and not having the additional expense?

Any and all advice will be much appreciated. This entire insurance process is deeply opaque and frustrating.

 

[Larra]

I understand your disappointment. And anger. And frustration. And I agree with you completely that this bmi requirement is arbitrary and that there is no evidence based justification for it. And you can appeal, though it is clear at this point that any internal appeals will fail. So, do you have external appeals rights? Your policy (you know, the one they are throwing in your face) would have this information. If so, you can try that, though you would have to use up your internal appeals first. Sometimes external appeals work, not always, even when the reason for the denials has nothing to do with evidence based medicine and everything to do with your policy being a contract and saving the insurer a few bucks.
On the other hand... I have to say, $3000 to get from a VSG to a DS is cheap. Dr. Keshishian, for example, has a "program fee" of $3000 for a DS and $4000 for revisions to DS, not because he's trying to gouge anyone, but because insurance reimbursements are not what they should be for the time and expertise that goes into this operation. So I think it's their idiocy and intransigence that may be sticking in your craw at this point. Of course, it's not my $3000 that we're talking about, so easy for me to say.
Your health and quality of life are worth far more than 3K. If you have the money, I think you should grab this offer with both hands and get yourself a date as soon as your schedule will allow.

 

[DianaCox]

My copay for my DS was $4500 14 years ago.

You have been denied, so your right to appeal is vested. I would self-pay for the switch and - carefully making sure you meet the deadline for appeal - file an appeal afterwards to get reimbursed.

 

[southernlady]

What Diana said. Go ahead and self pay for the switch part so you can force them to repay you.

 

[Stefanie S.]

I'm sorry you are dealing with this. Wanted to tell you where I'm at with a very similar story. I had my VSG 3 years ago... revised to DS this January. BCBS denied me. Denied the peer-to-peer. BCBS medical director denied. 1st appeal denied. And I just sent in my 2nd appeal. I'm not feeling hopeful. It seems that BCBS is NOT in favor of a revision to a DS, and I paid $29,000 for the revision. So........ $3000 to get the DS sound super cheap to me and I'd jump on that opportunity! Best wishes!

 

[Butterfly]

Chiming in that I think all things considered, $3000 sounds like a good deal.

 

[marissamast]

Best $3000 you will ever spend.

 

[DSRIGGS]

I agree with the ladies. The frustration is understandable but the $3,000 is a bargain and you may be able to get it back on appeal after you have the procedure. Best wishes to you and hopefully we see you soon on the DS side.

 

[Whit]

Yeah I'm on the bandwagon I recommend paying then appealing asap after surgery. Good luck and congratulations on what was approved and the option you have been given!

 

[writegirl]

Thank you all for your sound advice. You've all really put that $3000.00 in perspective. I just got off the phone with my surgeon's office and let my patient advocate know my decision--I'm going for the DS! She needs to now get the surgeon to submit a recommendation for the VSG portion of the surgery to BCBS, so now I need to wait (again) for approval since it's got to be resubmitted. I'm also awaiting a call from the office manager because, not for nothing, but the reason I got into this frustration in the first place is because the office initially told me that the BPD-DS is covered by my insurance. I suppose they never looked up the BMI requirement. I find that kind of unacceptable because they do these surgeries day in and day out. They *should* know this stuff. I feel like the surgeon should knock a few bucks off on his end (he won't), but I am going to persist in asking for that recompense. At any rate, fingers are crossed now for a quick and painless approval for the VSG portion of the surgery and then an prompt surgery date!

I probably should not be this ecstatic at the idea of having my intestines re-routed and my stomach all rejiggered, but I am. I just want to get free from this prison of fat and I want to stay free. I feel like the DS is my ONLY option if I really want to win the battle against morbid obesity.

Hugs to each of you for being so supportive and chiming in to help--it means so much to have this community to turn to

 

[Larra]

Good decision! 3K is nothing compared to the value of your health and quality of life.

 

[Susan in Tennessee]

Thank you all for your sound advice. You've all really put that $3000.00 in perspective. I just got off the phone with my surgeon's office and let my patient advocate know my decision--I'm going for the DS! She needs to now get the surgeon to submit a recommendation for the VSG portion of the surgery to BCBS, so now I need to wait (again) for approval since it's got to be resubmitted. I'm also awaiting a call from the office manager because, not for nothing, but the reason I got into this frustration in the first place is because the office initially told me that the BPD-DS is covered by my insurance. I suppose they never looked up the BMI requirement. I find that kind of unacceptable because they do these surgeries day in and day out. They *should* know this stuff. I feel like the surgeon should knock a few bucks off on his end (he won't), but I am going to persist in asking for that recompense. At any rate, fingers are crossed now for a quick and painless approval for the VSG portion of the surgery and then an prompt surgery date!

I probably should not be this ecstatic at the idea of having my intestines re-routed and my stomach all rejiggered, but I am. I just want to get free from this prison of fat and I want to stay free. I feel like the DS is my ONLY option if I really want to win the battle against morbid obesity.

Hugs to each of you for being so supportive and chiming in to help--it means so much to have this community to turn to

I'm really excited for you! I'd also get that promise of $3,000 confirmed somehow! What about hospital, anesthetia, etc? Will there be any additional charge for the switch portion in those areas? Is the $3,000 everything or strictly the surgeons switch part. I do not trust without verification in matters involving costs, doctors and INSURANCE companies!

 

[writegirl]

I'm really excited for you! I'd also get that promise of $3,000 confirmed somehow! What about hospital, anesthetia, etc? Will there be any additional charge for the switch portion in those areas? Is the $3,000 everything or strictly the surgeons switch part. I do not trust without verification in matters involving costs, doctors and INSURANCE companies!

They called with the approval for the sleeve portion and told me I have to pay the entire $4000.00 before they will schedule me for anything further. It kind of pisses me off. I have already paid $500 of the $1500.00 pre-surgery fee that is required by the surgeon. So, now I have to pay the $1000.00 (which I was expecting) but also the $3000.00 "hospital fees" that is the "difference."

I'm going to related my irritation to the surgeon and his office at some point, but right now I just want to get my surgery scheduled. I need to now wait to do that because I don't have an extra $3000.00 just laying around, so it will be into next week or the following week before I get to even schedule my procedure.

 

[Clematis]

Yeah I feel for you. The doctor and hospital made me pay my LBL charges a MONTH in advance. I understand wanting it in advance -- they can't undo the plastic surgery they did if I don't pay post-op -- but why a MONTH?? A nurse said that people get scared and back out at the last minute and then surgeon and hospital have a full day OR slot set aside and no revenue coming in. Oh poor dears! Pffft. I was unsympathetic.

But you will soon forget all this crap they put you through. You gonna get the DS!!! Yay YOU!!!! When's the big day?

 

[writegirl]

Yeah I feel for you. The doctor and hospital made me pay my LBL charges a MONTH in advance. I understand wanting it in advance -- they can't undo the plastic surgery they did if I don't pay post-op -- but why a MONTH?? A nurse said that people get scared and back out at the last minute and then surgeon and hospital have a full day OR slot set aside and no revenue coming in. Oh poor dears! Pffft. I was unsympathetic.

But you will soon forget all this crap they put you through. You gonna get the DS!!! Yay YOU!!!! When's the big day?

Thanks! I don't have a date yet because they won't schedule it until I pay the $4000.00 :'(