Turned in insurance info to Dr. Keshishian...

[Melanie0574]

Now I just have to wait to hear what they say.

 

[Kristaz]

I submitted all of my insurance stuff to him today to... Now crossing my fingers that the insurance co. approves!

 

[CaraOC]

Fingers crossed for both of you guys!!!

 

[duh_Mom]

I firmly believe that the whole insurance debacle is the hardest part of the whole DS experience. You have both selected an excellent surgeon. My thoughts are with you.

 

[Melanie0574]

Well I got a call from there office,and I guess they do not accept my insurance.

 

[Larra]

@Melanie0574 I'm sorry to hear this but not surprised. It's pretty much what we expected, though it was worth a try. I still think you could at least contact Dr. Coates's office to see if one of them (it's a father and son, I believe) is doing the DS and if so, would they accept your insurance. this isn't a perfect solution, but you can only work with the options available to you. If that doesn't pan out, I would go with Dr. Esquerra in Mexico.

 

[DianaCox]

There is one other option - if your insurance company does NOT have a DS surgeon in-network, you are STILL entitled to have a DS from an out-of-network surgeon. What will be required is that you follow these steps:

• Go to a pre-op appointment with an in-network bariatric surgeon, and request that you get a DS.
• If s/he says s/he doesn't do the DS, ask for a referral to an in-network surgeon who does.
• When it turns out there isn't one, file a grievance with your insurance company, asking for a referral out of network to a DS surgeon, since there is no in-network DS surgeon, preferably Dr. Keshishian.
• When they deny the referral, you file an appeal (after doing the next step, which comes after the denial but before filing the appeal).
• You go to Dr. K for a consult (self-pay - probably $300-500, which will be reimbursed if you win the appeal) and he writes you a letter of medical necessity saying why the DS would be best for you, and you use that in your appeal.
• Your appeal will probably be denied twice, to exhaust your internal appeals, and then you file for Independent Medical Review with the CA Dept. of Managed Health Care (DMHC).
• Far more often than not, you will win the IMR.
• Then your insurance company will have to pay Dr. K's fee.

It will obviously take about 6 months to get through this process.

 

[Melanie0574]

Thank you @DianaCox . I got a referral from my doctor for a local baractric surgeon, but he only offers the lapband,and sleeve. I will make an appointment with him,and start the process you described.

 

[Marquis Mark]

BTW, I had a self-pay consult with Dr. K last year. It was only $112.

 

[DSRIGGS]

I submitted all of my insurance stuff to him today to... Now crossing my fingers that the insurance co. approves!

Are you BCBS? I have BCBS PPO and was approved without any issues


Good luck

 

[Melanie0574]

BTW, I had a self-pay consult with Dr. K last year. It was only $112.

This is good to know. Thank you!

 

[Kristaz]

Are you BCBS? I have BCBS PPO and was approved without any issues


Good luck

I am BCBS of AZ and it's a Ppo. The DS and revision to DS are covered procedures. I did all the pre-op requirements and they submitted for approval my only concern is my low BMI (31ish) but my primary reason is he severe dumping so hopefully it won't be an issue and they will approve with no problems!

 

[DSRIGGS]

I am BCBS of AZ and it's a Ppo. The DS and revision to DS are covered procedures. I did all the pre-op requirements and they submitted for approval my only concern is my low BMI (31ish) but my primary reason is he severe dumping so hopefully it won't be an issue and they will approve with no problems!

I was BCBS PPO as well (Indiana even though we live in IL)

 

[southernlady]

BCBS PPO means nothing...
Each BCBS is an individual company EVEN tho they may have BCBS in their name. So BCBS TN is a different company from BCBSNC.

Then add to the mix, employer. An employer is allowed to NOT pay for bariatric surgery for their employees.

Then there is the BCBS ACA plans, each state has a say in what has to be offered.

Add to that, regular PPO and REGIONAL PPO's.

That is why we tell people to look at THEIR OWN Evidence of Coverage document for their own policy regardless of the plan.

 

[Kristaz]

BCBS PPO means nothing...
Each BCBS is an individual company EVEN tho they may have BCBS in their name. So BCBS TN is a different company from BCBSNC.

Then add to the mix, employer. An employer is allowed to NOT pay for bariatric surgery for their employees.

Then there is the BCBS ACA plans, each state has a say in what has to be offered.

Add to that, regular PPO and REGIONAL PPO's.

That is why we tell people to look at THEIR OWN Evidence of Coverage document for their own policy regardless of the plan.

Thank you! I did check mine. Bariatric surgery and more importantly for me revision surgery. Submitted all of there pre requisites and now cross my fingers. My only fear is too low BMI. Dr K hopes the "letter of necessity" he writes will be enough.