Revision from Sleeve to DS

[southernlady]

Ok. Thank you for making that clear! I feel so much better about this. I plan on asking for a sleep study this Thursday at my pcp appointment and then maybe submit after that.

Also Medicare and the NIH do not limit the DS to above 60.

I had BCBSTN Medicare when I had my DS at a 35.2 BMI with comorbids.

 

[cdixon]

You are having a CONVERSION to another procedure, not a revision/correction. Different rules. I don’t see anything limiting the DS to BMI > 60, or even 50, and no such policy is medically justified based on evidence-based medicine. The ASMBS has no such recommendation.

I went on a search and found this picture of the denial from almost a year ago when I applied the 1st time. I do not have the full letter just this picture. What are you thought on it? Do you think it was denied because the surgeon coded it incorrectly?

 

[DianaCox]

It is confusing that the requirements that they say in the letter you didn’t meet don’t align with the requirements in the BCBS policy statements.

 

[cdixon]

It is confusing that the requirements that they say in the letter you didn’t meet don’t align with the requirements in the BCBS policy statements.

So do you think that I would have a chance at overturning a denial since they do not align? Is there anything else I should be looking for? Is there something specific that I should ask my surgeon to add before submitting this time?

 

[DianaCox]

There’s always a chance, and usually a good one.

I would prepare a Word draft of a letter for your surgeon to complete and put on his letterhead. It should be organized as follows:

• Requesting preauthorization for CONVERSION of your VSG to DS because of insufficient weight loss/regain.
• Summary of your weight loss/medical history, including pre and postop weight and BMI, and evidence of compliance.
• Summary of reasons for denial
• Summary of ACTUAL conversion criteria from BCBS policy
• Note there is no BMI limitations in policy, and that there is no evidence-based medical rationale for such a limitation; cite ASMBS reoperation policy statement.

 

[cdixon]

There’s always a chance, and usually a good one.

I would prepare a Word draft of a letter for your surgeon to complete and put on his letterhead. It should be organized as follows:

• Requesting preauthorization for CONVERSION of your VSG to DS because of insufficient weight loss/regain.
• Summary of your weight loss/medical history, including pre and postop weight and BMI, and evidence of compliance.
• Summary of reasons for denial
• Summary of ACTUAL conversion criteria from BCBS policy
• Note there is no BMI limitations in policy, and that there is no evidence-based medical rationale for such a limitation; cite ASMBS reoperation policy statement.

Thank you. I will work on this. Would it be ok for me to send it to you to get your opinion before I submit it?

 

[DianaCox]

Absolutely - Larra should be invited to comment as well.

 

[cdixon]

There’s always a chance, and usually a good one.

I would prepare a Word draft of a letter for your surgeon to complete and put on his letterhead. It should be organized as follows:

• Requesting preauthorization for CONVERSION of your VSG to DS because of insufficient weight loss/regain.
• Summary of your weight loss/medical history, including pre and postop weight and BMI, and evidence of compliance.
• Summary of reasons for denial
• Summary of ACTUAL conversion criteria from BCBS policy
• Note there is no BMI limitations in policy, and that there is no evidence-based medical rationale for such a limitation; cite ASMBS reoperation policy statement.

I apologize for so many questions, I really don't want to wear out my welcome. Would you mind clarifying what you mean by summary of reasons for denial? Are you referring to my past denial? Thanks.

 

[DianaCox]

Maybe I misunderstood - you are not currently denied? If not, don’t mention it. Just copy the BCBS written policy requirements to qualify for conversion and then cite evidence in your medical records proving you meet them.

 

[cdixon]

Maybe I misunderstood - you are not currently denied? If not, don’t mention it. Just copy the BCBS written policy requirements to qualify for conversion and then cite evidence in your medical records proving you meet them.

Correct. I am not currently denied. I am currently waiting on approval for a test to possibly prove a complication before submitting for the 2nd time. I am just preparing for the worse. I hate to be negative but I'm certain I will be denied once again. I hope I'm wrong but if not I want to be prepared to fight it and not give up this time.

Now that you pointed out that it is a conversion and not complication revision I wonder if I should move forward without the test even if it is approved?

 

[DianaCox]

I’d go ahead and do the test - if you have a mechanical reason for failure it could help; if not, it shouldn’t matter because it’s nit a requirement for a conversion.

 

[cdixon]

There’s always a chance, and usually a good one.

I would prepare a Word draft of a letter for your surgeon to complete and put on his letterhead. It should be organized as follows:

• Requesting preauthorization for CONVERSION of your VSG to DS because of insufficient weight loss/regain.
• Summary of your weight loss/medical history, including pre and postop weight and BMI, and evidence of compliance.
• Summary of reasons for denial
• Summary of ACTUAL conversion criteria from BCBS policy
• Note there is no BMI limitations in policy, and that there is no evidence-based medical rationale for such a limitation; cite ASMBS reoperation policy statement.

I spoke with my coordinator about me writing a letter. I asked about putting it on there letterhead with the surgeon's approval of course and she said that they will not do that. She said they will write there own letter. She did said they encourage patients to write a letter though. My question is should I still approach the letter as you suggested above?

 

[DianaCox]

Absolutely write your own letter! We were going to have you do it anyway.

 

[Susan in Tennessee]

Absolutely write your own letter! We were going to have you do it anyway.

Maybe you could still try giving some notes to your surgeon to “not forget to include”. couldn’t hurt.

 

[cdixon]

Maybe you could still try giving some notes to your surgeon to “not forget to include”. couldn’t hurt.

That's a great idea. Thank you