Revision from Sleeve to DS

[Larra]

I would not accept this answer from the coordinator. It's up to the doctor whether or not he/she would accept your help, with the understanding that he/she would review the letter personally and could edit/add/subtract/alter as desired before using it.

 

[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 have attached a draft of my letter to add with the surgeon's pre-authorization to BCBS for approval for a conversion from Sleeve to DS. I am waiting on appointment for a sleep apnea test. I am also waiting for my surgeon to have a peer to peer with BCBS for a test to measure the size of my sleeve. They did not approve the initial request for the test. Hopefully I will get these test completed and will have helpful information to add to the letter. Below are the requirements from the BCBSTN medical Policy Manual. I outlined these in the letter. I appreciate any feed back. THANKS

• subsequent bariatric procedure that is a conversion of a previous bariatric procedure to a different type of bariatric surgery with ALL of the following:
  • The requested procedure is not an investigational procedure
  • Individual meets all of the criteria for an initial bariatric procedure (Note: documentation submitted for the initial bariatric surgery does not count toward meeting the criteria for the conversion procedure, all documentation must be resubmitted)
  • Request is two (2) years or more since the initial surgery
  • Weight loss is less than 50% of initial procedure pre-operative excess body weight
  • Weight remains at least 30% over ideal body weight (using standard tables for adult weight ranges from the National Heart Lung and Blood Institute: http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm)
• 
  
• An initial bariatric surgical procedure requested and ALL of the following:
• • Individual is 18 years of age or older
  • The Bariatric Surgery Precertification Request Form completed and submitted with the request for authorization
  • Diagnosis of morbid obesity classified as ANY ONE of the following:
  • • Class 3 obesity with a BMI greater than or equal to 40 kg/m2
    • Class 2 obesity with a BMI 35 to 39.9 kg/m2 with ANY ONE of the following obesity related comorbidities:
    • • Coronary artery disease
      • Type 2 diabetes mellitus
      • Obstructive sleep apnea
      • Hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic)

 

[DianaCox]

Very good letter! I have two comments:

1) Your medical policy distinguishes between revision (fixing an existing surgery) and conversion (changing to a different procedure) - you are requesting conversion, so make sure you use the right word throughout the letter: “Duodenal Switch is a natural [revision] conversion option ...”

2) Your math is wrong:

“Weight loss is less than 50% of initial procedure pre-operative excess body weight

My pre-procedure weight was 284 lbs. Eighteen monthsafter I had my procedure, I weighed 188 lbs., which is the lowest I weighed after my procedure but is only a 33% weight loss and is less than the 50% weight loss threshold as stated in the BCBS policy. Currently I weigh 303 lbs.”

If your start weight was 284 and your goal weight (normal) was 144, your EXCESS weight was 140 lbs; and you lost 96 lbs, or - at best, your EXCESS weight loss was almost 69%. You initially did reasonably well.

However, your LONG-TERM excess weight loss is a negative number, as you are now heavier than you were prior to your first surgery.

 

[cdixon]

Very good letter! I have two comments:

1) Your medical policy distinguishes between revision (fixing an existing surgery) and conversion (changing to a different procedure) - you are requesting conversion, so make sure you use the right word throughout the letter: “Duodenal Switch is a natural [revision] conversion option ...”

2) Your math is wrong:

“Weight loss is less than 50% of initial procedure pre-operative excess body weight

My pre-procedure weight was 284 lbs. Eighteen monthsafter I had my procedure, I weighed 188 lbs., which is the lowest I weighed after my procedure but is only a 33% weight loss and is less than the 50% weight loss threshold as stated in the BCBS policy. Currently I weigh 303 lbs.”

If your start weight was 284 and your goal weight (normal) was 144, your EXCESS weight was 140 lbs; and you lost 96 lbs, or - at best, your EXCESS weight loss was almost 69%. You initially did reasonably well.

However, your LONG-TERM excess weight loss is a negative number, as you are now heavier than you were prior to your first surgery.

Thank you for your feedback I will make some changes.

 

[cdixon]

I got a denial in the mail today. I will attach a pic of the reason. This is a huge punch to the gut. Any help would be appreciated. My weight before initial surgery was 285 lowest weight was around 185 and I am 5' 5. And at 300 now. I am waiting on a call back from my surgeon's office.

 

[DianaCox]

What are the deficiencies in documentation? They need to give you a detailed description so you can remedy or appeal!

 

[cdixon]

What are the deficiencies in documentation? They need to give you a detailed description so you can remedy or appeal!

I called bcbs and the lady I spoke to was near incompetent. I am so frustrated. She said that since I lost 50% of my excess body weight with the sleeve and there is not a compilation of the sleeve to cause weight gain I was denied. I then ask her if they did not coinsider the test that showed that my sleeve was enlarged. She said yes and referenced a note from my initial surgeon saying that the enlargement was due to overeating. Note I have not seen this surgeon in over 1.5 years. My new surgeon is the one who ordered the test and submitted for insurance approval. I am waiting on a call back from the surgeons office. I hope this makes sense.

 

[Georgepds]

Fighting the insurance company is always a good fight

But, if finances permit, many here have successfully financed their own surgery in Mexico

Might get you where you want to go a bot quicker