To get help with Insurance Denials for WLS/Revisions

southernlady

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1) You need to have a hard copy of your Evidence of Coverage. NOT the generic policy that an insurance company puts out but the one that applies to JUST YOU.

2) IF you have been denied, have a copy of the letter handy so you can tell people WHY it was denied.

3) Be prepared to bare your entire medical history to the two people who help others get their surgery. Be advised that you will need to be very open about your present situation, medical history and such, because there is no way a strong case for the medical necessity for a DS or a revision without knowing quite a bit about you.

Now I do understand that posting that information is not what most people want to do on an open forum... HOWEVER, tagging the two people most likely to help and give some basic info without whining or feeling entitled will go far in helping you get the surgery you want.

How to tag: Type the at symbol @
Then start typing the user names of the two people who are able to help:
They are Diana Cox and Larra.
So to tag them: @DianaCox and @Larra is how it will look.

Once they are aware that you need help, they will talk to you privately.
 
@DianaCox
Happy Monday! Just got off the phone with my insurance company (ChampVA) and ran some procedure codes by them. 43845 (DS) is not covered, but 43848 (revision) is covered. I currently have a VSG and was hoping to revise to DS. I'm assuming that despite the fact they already have excluded the DS that they wouldn't allow a revision to DS regardless of the revision procedure code. ChampVA does not require preauthorization for bariatric surgery so I do not feel comfortable in going for surgery and getting stuck with a bill later.
 
This is the (ridiculously outdated) medical policy for CHAMPSVA: http://www.va.gov/PURCHASEDCARE/pubs/champva_policy.asp
Top > Chapter 2 Benefits > Chapter 2 Section 29.15​
TRANSMITTAL #: 128
DATE: 12/23/2011
TRICARE CHANGE #: C-144

"V. EXCLUSION(S)
***​
C.Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) for treatment of morbid obesity is unproven (CPT procedure codes 43645, 43845, 43847, or 43633)."

The requirements for revision:

C.Revision Bariatric Surgery.

1.Medically necessary surgical reversal, that is, takedown or revision of the bariatric procedure is covered when the beneficiary develops a complication, such as stricture or obstruction from the original covered surgery.

2.Replacement of an adjustable band because of complications, such as port leakage, slippage that cannot be corrected with band manipulation or adjustments is covered.

3.Repeat/revision of a covered bariatric surgical procedure due to technical failure of the original procedure is covered when all of the following criteria are met:​

a.The patient has failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body weight or failure to achieve body weight to within 10% of ideal body weight at least two years following the original surgery.

b.The patient met all the screening criteria, including BMI requirements of the original procedure, and has been compliant with a prescribed nutrition and exercise program following the original surgery.

c.The requested procedure is a covered bariatric surgery.

NOTE: Inadequate weight loss due to individual noncompliance with postoperative nutrition and exercise recommendations is not a medically necessary indication for revision or conversion surgery and is not covered.

I suspect that your surgery will NOT be covered. And I don't know how you can get CHAMPSVA to admit that the DS is DIFFERENT from the BPD (Scopinaro) procedure, that it is NOT unproven (ASMBS said it was standard of care in 2004; Medicare covers it); AND - their own surgeons at Madigan Army Medical Center, Ft Lewis, Washington, have been performing it for years. (Can you get surgery there??)

http://archsurg.jamanetwork.com/article.aspx?articleid=1358524
Sep 2012
Analysis of Obesity-Related Outcomes and Bariatric Failure Rates With the Duodenal Switch vs Gastric Bypass for Morbid Obesity FREE
Daniel W. Nelson, DO; Kelly S. Blair, MD; Matthew J. Martin, MD
[-] Author Affiliations

Author Affiliations: Department of Surgery, Madigan Army Medical Center, Ft Lewis, Washington.

Perhaps you can get a pre-authorization appeal?
 
@DianaCox and @Larra:

I am on my external review and have been denied all internal levels up until this point. Any documentation I can provide must be done by Monday, August 29, 2016. I am sorry for the short notice, but just found this forum today.

Coverage is Personal Choice.
Initial Surgery in April of 2009:
  • Highest weight was 253 lbs.
  • Weight at time of surgery was 227 lbs and 5'5" in height. (BMI = 37.8)
Pre- surgery: Arthritis, hypothyroidism, medically supervised weight loss.
Post surgery: Consistent steady weight loss. Lowest weight maintained was 152 lbs.
  • Partial unfill in 2011 at doctor's request (due to 1 yr of unexplained infertility.)
  • Complete unfill in fall 2011 due to pregnancy :)
  • Separated pelvis midway through pregnancy required mandatory bedrest. Healthy baby boy in June 2012!
  • Post surgery refills resulted in no weight loss, violent vomiting of all solids and liquids. Multiple unfills/ adjustments over the years.
  • Surgeon left practice with no notice. Subsequent doctor left practice with no notice but I was told prior to his departure that lap band stops working for upwards of 40% of patients with no explanation. Owner of the practice denied this when I mentioned it to him and recommended a complete unfill but no means of correction.
  • Severe reflux/ GERD developed. Went to new practice. Was on Nexium for 3 yrs at this point.
  • Continued vomiting from Summer 2012 to fall of 2015 when lap band was completely unfilled.
  • GERD worsened and I was taking 4X the recommended dosage of Nexium while waiting for removal (as per doctor's instructions).
  • February 2016 removed due to complete obstruction, dilated pounch, dilated esophagus.

  • Current Medical Conditions:
    • prediabetic
    • celiac disease
    • hypothyroidism (doctor cannot get it under control, despite maximum dosage; believes it is due to celiacs not allowing meds to absorb into my body. Theoretically, bypass would make this a non-issue.)
    • iron deficient anemia that requires IV infusions every 3- 6 months
    • sleep disorder (not apnea)
    • morbid obesity (current weight 270 lbs/ bmi 44.9)
    • arthritis
    • acid reflux
    • hair loss
    • chronic fatigue
Application timeline for gastric bypass thus far:

  • May 27, 2016 applied and was "ADMINISTRATIVELY DENIED based upon the terms of your PPO contract. Bariatric surgery is limited to one surgical procedure in a lifetime".
  • Appealed June 14 and was denied on July 1,2016. "The medical necessity appeal involved the precertification denial of Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y (code 43644)" "Denial: Bariatric procedure is limited to once in a lifetime."
  • Appealed July 28 and was denied August 12, 2016. again, once in a lifetime. "The exclusion of coverage for repeat, reversal or revision of a previous obesity surgery does not apply when the procedure results in technical failure or when the procedure is required to treat complications, which if left untreated wouild result in endangering the heqalth of the member." IBC medical policy# 11.03.02p
Sorry for the lengthy post. I only have 5 business days to get this figured out and again, I just found this forum today. This is the last level of appeal allowed.
 
@DianaCox and @Larra:

I am on my external review and have been denied all internal levels up until this point. Any documentation I can provide must be done by Monday, August 29, 2016. I am sorry for the short notice, but just found this forum today.

Coverage is Personal Choice.
Initial Surgery in April of 2009:
  • Highest weight was 253 lbs.
  • Weight at time of surgery was 227 lbs and 5'5" in height. (BMI = 37.8)
Pre- surgery: Arthritis, hypothyroidism, medically supervised weight loss.
Post surgery: Consistent steady weight loss. Lowest weight maintained was 152 lbs.
  • Partial unfill in 2011 at doctor's request (due to 1 yr of unexplained infertility.)
  • Complete unfill in fall 2011 due to pregnancy :)
  • Separated pelvis midway through pregnancy required mandatory bedrest. Healthy baby boy in June 2012!
  • Post surgery refills resulted in no weight loss, violent vomiting of all solids and liquids. Multiple unfills/ adjustments over the years.
  • Surgeon left practice with no notice. Subsequent doctor left practice with no notice but I was told prior to his departure that lap band stops working for upwards of 40% of patients with no explanation. Owner of the practice denied this when I mentioned it to him and recommended a complete unfill but no means of correction.
  • Severe reflux/ GERD developed. Went to new practice. Was on Nexium for 3 yrs at this point.
  • Continued vomiting from Summer 2012 to fall of 2015 when lap band was completely unfilled.
  • GERD worsened and I was taking 4X the recommended dosage of Nexium while waiting for removal (as per doctor's instructions).
  • February 2016 removed due to complete obstruction, dilated pounch, dilated esophagus.

  • Current Medical Conditions:
    • prediabetic
    • celiac disease
    • hypothyroidism (doctor cannot get it under control, despite maximum dosage; believes it is due to celiacs not allowing meds to absorb into my body. Theoretically, bypass would make this a non-issue.)
    • iron deficient anemia that requires IV infusions every 3- 6 months
    • sleep disorder (not apnea)
    • morbid obesity (current weight 270 lbs/ bmi 44.9)
    • arthritis
    • acid reflux
    • hair loss
    • chronic fatigue
Application timeline for gastric bypass thus far:

  • May 27, 2016 applied and was "ADMINISTRATIVELY DENIED based upon the terms of your PPO contract. Bariatric surgery is limited to one surgical procedure in a lifetime".
  • Appealed June 14 and was denied on July 1,2016. "The medical necessity appeal involved the precertification denial of Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y (code 43644)" "Denial: Bariatric procedure is limited to once in a lifetime."
  • Appealed July 28 and was denied August 12, 2016. again, once in a lifetime. "The exclusion of coverage for repeat, reversal or revision of a previous obesity surgery does not apply when the procedure results in technical failure or when the procedure is required to treat complications, which if left untreated wouild result in endangering the heqalth of the member." IBC medical policy# 11.03.02p
Sorry for the lengthy post. I only have 5 business days to get this figured out and again, I just found this forum today. This is the last level of appeal allowed.


Oops, forgot last line: applied for external review appeal onAugust 12, 2016.
 
1) You need to have a hard copy of your Evidence of Coverage. NOT the generic policy that an insurance company puts out but the one that applies to JUST YOU.

2) IF you have been denied, have a copy of the letter handy so you can tell people WHY it was denied.

3) Be prepared to bare your entire medical history to the two people who help others get their surgery. Be advised that you will need to be very open about your present situation, medical history and such, because there is no way a strong case for the medical necessity for a DS or a revision without knowing quite a bit about you.

Now I do understand that posting that information is not what most people want to do on an open forum... HOWEVER, tagging the two people most likely to help and give some basic info without whining or feeling entitled will go far in helping you get the surgery you want.

How to tag: Type the at symbol @
Then start typing the user names of the two people who are able to help:
They are Diana Cox and Larra.
So to tag them: @DianaCox and @Larra is how it will look.

Once they are aware that you need help, they will talk to you privately.
 
Obviously, without further information, neither Larra nor I can tell you anything.

The first thing you need to do is to get a copy of your Evidence of Coverage - this is the contract with your insurance company (100+ pages, generally - NOT the summary of benefits). Your HR department has it, not the insurance company. You also need to get a copy of your insurance company's bariatric surgery policy - the policies vary widely and you must know what applies to YOU. Larra and I will need to see your denial, and the letter of medical necessity/request for preauthorization your surgeon submitted, so we can see what he did wrong and needs to be fixed. I will send you PM with my email address, so you can send these things to me by email once you get them, and with your permission I will share with Larra - it is better to do these things through email (for convenience of sharing documents and for privacy).
 
DianaCox I have a bariatric exclusion with United Heath Care. I have the lap band and would like the RNY surgery. I contacted a dcotor in dallas that can help me but they are not in network. I have a PPO so my in network and out of network benefits are the same. She said "we will code this as a gastric reconstruction when it’s time to submit to the insurance. Before we can do that we need to schedule the endoscopy." Have you ever heard of this? After the doctor goes in and checks everything, I can possibly have the lap band removed and have the gastric paid for she seems to think...BUT no other doctor around was willing to help me. ALL the office staff other places just called back and said you will have to be a cash pay. SO I prepared for the worse and have the funds available. I have gone to two other doctors and have an appointment with another the same week I am doing this endoscopy just in case. This other surgeon is much cheaper than all 3. I have even considered mexico but I can't be away from home that long with my 3 kids at home and a husband to care for them he works odd hours. Just wondering if you have ever heard of this and if you have seen any luck from it. You seem to be an expert. Thank you:D
 
Before we go down this path, I would like to suggest you first look at the post above about the superiority of the DS over RNY (gastric bypass) - be certain of which surgery to want to convert to first. And get a copy of your EoC as well.

Larra
 
Before we go down this path, I would like to suggest you first look at the post above about the superiority of the DS over RNY (gastric bypass) - be certain of which surgery to want to convert to first. And get a copy of your EoC as well.

Larra
OK thank you. I just wondered if you have ever had this issue of insurance. Not sure the surgeon does DS I believe he only does sleeve and RYN.
 

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