journiewilde

Hi all, I have Wellmark BCBS of Iowa and am about two weeks away from submitting pre-approval, so just reading over the WLS coverage on their site. VSG is listed as "investigational", which is bolded like it's important, but not explained. RNY gastric bypass is listed as "may be medically necessary when criteria below are met". I am having zero luck finding a good explanation of what the difference is, on the site. Can anyone clue me in to what that means in insurance terms, and what it may mean to my preapproval application? If it matters, my BMI right now is 49.6. Also, anyone else have Wellmark Iowa (not federal) and have any luck? Thank you for any help! Here is the verbiage from the website: Medical Policy: 07.01.17 Original Effective Date: September 1995 Reviewed: September 2009 Revised: September 2009 Benefit Application Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program. This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available. Description: Obesity is the most frequent form of malnutrition in the developed world and it is increasing. Morbid obesity (i.e., obesity with secondary serious or debilitating progressive disease) is generally associated with a body mass index (BMI) of ≥40 kg/m² (i.e. weight/height squared). Morbid obesity has a significant impact on cardiac risk factors, incidence of diabetes, obstructive sleep apnea, debilitating arthritis of weight bearing joints, infertility, psychosocial and economic problems and various types of cancers, etc. The first treatment of morbid obesity is dietary and lifestyle changes. When conservative treatment fails, a few patients may require a surgical approach. The National Institutes for Health defines potential candidates for surgery as those with a BMI of 40 kg/m² or more or a BMI between 35 kg/m² and 39.9 kg/m² and a serious obesity-related health problem such as type 2 diabetes, coronary heart disease, or severe sleep apnea. Additionally, persons should have acceptable operative risks, the ability to participate in treatment and long-term follow-up, and possess an understanding of the surgical procedure and necessary life style changes. Surgery for morbid obesity, also known as bariatric surgery is based on intestinal malabsorption and gastric reduction. Surgery is considered successful if weight loss is maintained at greater than or equal to 50% of excess body weight for more than 10 years. Several different gastric reduction and intestinal malabsorption procedures are listed below: Gastric reduction (gastric restrictive) procedures: * Vertical-banded gastroplasty * Adjustable gastric banding * Gastric bypass (Roux-en-Y gastroenterostomy); this can be done by both open or laparoscopic approach * Mini-gastric bypass (laparoscopic) * Sleeve gastrectomy; performed on its own or in combination with malabsorptive procedures. Malabsorptive Procedures: * Biliopancreatic bypass (Scopinaro Procedure) * Biliopancreatic bypass with duodenal switch Top Prior Approval: Prior approval is recommended for this service. Submit a prior approval now. Top Policy: The following surgical procedures for the treatment of morbid obesity may be considered medically necessary when the criteria listed below are met: * Vertical-banded gastroplasty * Gastric bypass (Roux-en-Y gastroenterostomy) with short Roux limb equal to or less than 150 cm; this can be done by either open or laparoscopic approach * Adjustable gastric banding (Lap-Band® procedure) * Biliopancreatic bypass (i.e., the Scopinaro procedure) with duodenal switch; this can be done by either open or laparoscopic approach Criteria for Coverage: * Patient is at least 18 years old And * The patient must have documentation in the medical record of failure to sustain weight loss within the two years preceding surgery and documentation of the health care provider’s monitoring of the patient’s progress toward a goal of weight loss. And * The patient must be a motivated individual with acceptable operative risk and must be evaluated by a licensed mental health provider to determine the patient's willingness to comply with pre and postoperative treatment plans, and a strategy to ensure cooperation with follow-up must be documented. And, in addition to the general requirements above, the patient must also meet one of the following weight criteria: * BMI of 40kg/m² for at least 3 years * BMI of ≥ 50 kg/m² for biliopancreatic bypass (i.e., the Scopinaro procedure) with duodenal switch Or * BMI of greater than 35kg/m² in conjunction with at least one of the following: o Hypertension requiring medication for at least one year o Diabetes Mellitus type 2 requiring medication for at least one year o Obstructive sleep apnea, confirmed by sleep study, which does not respond to conservative treatment o Documented cardiovascular disease o Pulmonary hypertension of obesity The following surgical procedures for the treatment of morbid obesity are considered investigational: * Sleeve gastrectomy as a stand alone procedure OR in combination with a malabsorptive procedure * Mini-gastric bypass (laparoscopic) * Biliopancreatic bypass (Scopinaro Procedure) * Long-limb ( > 150 cm) gastric bypass Endoscopic procedures, including but not limited to the StomaphyXTM device, to treat weight gain after bariatric surgery due to large gastric stoma or large gastric pouches are considered investigational. Bariatric surgery is considered investigational as a cure for type 2 diabetes mellitus. Subsequent bariatric procedures, including revisions, in patients who regain weight due to failure to comply with lifestyle or dietary modifications are considered not medically necessary.

WOOHOO! *happydance* Thank you for letting me know about this. My surgeon's office had decided to wait to apply until this was changed... I'm so glad!

Marking the thread for myself... I'm also very interested in this 'announcement'!

WeekendWarrior, did you ever hear what the announcement was or if it was made? I don't see any changes in the policy on the Wellmark site, but that hasn't necessarily been updated. I'm really hoping they would have a timely policy change, hehe. Thanks!

I've never watched ER, but I can tell you Grey's Anatomy is not a very good representation of just about anything that goes on in a hospital... At least, not any good hospital. :/ I work Med/Surg and occasionally PACU and as others have said, people are generally not aware enough to remember actually being extubated. Having been to surgery only once before myself, I wasn't awake enough to remember the tube coming out, I just remember having an oxygen mask on. Congratulations on your date! Don't let the little things get you down - you can do it!

That is crazy awesome! I am hoping to have all my ducks in a row to submit by the 19th or 20th, so if they suddenly started covering VSG without a hassle. That would be absolutely amazing. What (potentially) great news! Thank you. As far as traditional qualification, I would certainly qualify for RNY, but I do tend to take quite alot of NSAIDs (though for generalized pain and frequent headaches, not really for any real documented 'condition') and don't have any 'official' comorbidities, just a family history of diabetes and obesity, and some back and joint pain. Mostly, I'm trying to stop the train before it rolls too far downhill. Last psych consult and a wrap-up appointment with the surgeon's PA on the 19th of October, and submission after that... Wish me luck! Thank you for everybody's responses.

Hi, everyone! Just wanted to introduce myself. I've been lurking on the forums for awhile, and finally decided to register! My name is Molly, I'm 28 (29 in less than a week), from northeast Iowa. I'm hoping to have a VSG at Gundersen Lutheran in LaCrosse, WI sometime in spring of 2011. I'm still in the pre-approval process, but am hoping I'll be able to submit in mid-October. I'm a registered nurse and mom of two boys (13 months and 2 years), and (hopefully) headed back to school next summer for my DNP. I like to read, sing and play several instruments, and do freelance webdesign in my spare time (like I have any, with munchkins). I'm 5'5" and usually hover around the 300lb mark. As I've gotten older, I've started to have more in the way of body aches and loss of energy, asthma, etcetera, as well as the usual social stigma and the added fun of weight-related professional discrimination. I'm hoping the VSG will be an improvement in my overall health as well as my professional prospects. :/ VSG is a very new thing in the region (the doc I'm going with has only done 3 so far in that facility, but he seems pretty confident and they have a well-established RNY-GB program) so I'm not sure if there's anyone around, but I'm definitely looking for anyone (near or far) interested in striking up a relationship. If you like to read blogs, I am an avid journaler. I have a livejournal (which is friends-locked - I can send you info, though) about my daily life, and a separate journal that I've just started (verisimilitude.blog.com) for my WLS journey. Not much on there yet, as I've been reluctant to blog too much about it and jinx myself before that insurance approval goes through! So! If you have questions, please ask! - I'm enjoying reading the board and excited to get to know everyone.

Mine is requiring two visits. The first was an hour-long visit with a psychologist who asked general questions about my social situation, questions about mental health and substance abuse history, and "Why now?" with relation to the surgery. I also had to fill out an emotional eating questionnaire, and take two of those godawful-long personality 'tools' - the MMPI-2 and the MBMD. (Which are ridiculous, as others have said.) She is also making me schedule another hour-long appointment to "discuss my results" before I can be approved... At $632 a pop. Holy cats! I'm honestly not sure what the second visit is for. I have no psych history and thought the eval was a formality. :/ I think they're milking a trapped (and desperate) cow.