gviscio

We have just added a new page to our site that will give you a complete list of each State and how to contact the proper Insurance Regulatory agency in each State as well as a brief outline of that State's rights. You'll note some States have external reviews, some do not. Each State is different. Here is the link http://www.naic.org/state_web_map.htm click state by state link. Best of luck. Gary Viscio www.ObesityLawyers.Com RNY 7/1/03 -165lbs

go to another one just to get a follow up. they sometimes let you slide. they really want to see that you made an effort.

CIGNA may face murder charges over this one Family sues insurer who denied teen transplant - Health care - MSNBC.com MAybe it will hep us all out along the way if they finally look at how these companies look at patients, and make medical decisions. Gary

Use this in your appeals and also request for surgery JAMA -- Abstract: Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes: A Randomized Controlled Trial, January 23, 2008, Dixon et al. 299 (3): 316 Adjustable Gastric Banding and Conventional Therapy for Type 2 DiabetesA Randomized Controlled Trial John B. Dixon, MBBS, PhD; Paul E. O’Brien, MD; Julie Playfair, RN; Leon Chapman, MBBS; Linda M. Schachter, MBBS, PhD; Stewart Skinner, MBBS, PhD; Joseph Proietto, MBBS, PhD; Michael Bailey, PhD, MSc(stats); Margaret Anderson, BHealthMan JAMA. 2008;299(3):316-323. Context Observational studies suggest that surgically induced loss of weight may be effective therapy for type 2 diabetes. Objective To determine if surgically induced weight loss results in better glycemic control and less need for diabetes medications than conventional approaches to weight loss and diabetes control. Design, Setting, and Participants Unblinded randomized controlled trial conducted from December 2002 through December 2006 at the University Obesity Research Center in Australia, with general community recruitment to established treatment programs. Participants were 60 obese patients (BMI >30 and <40) with recently diagnosed (<2 years) type 2 diabetes. Interventions Conventional diabetes therapy with a focus on weight loss by lifestyle change vs laparoscopic adjustable gastric banding with conventional diabetes care. Main Outcome Measures Remission of type 2 diabetes (fasting glucose level <126 mg/dL [7.0 mmol/L] and glycated hemoglobin [HbA1c] value <6.2% while taking no glycemic therapy). Secondary measures included weight and components of the metabolic syndrome. Analysis was by intention-to-treat. Results Of the 60 patients enrolled, 55 (92%) completed the 2-year follow-up. Remission of type 2 diabetes was achieved by 22 (73%) in the surgical group and 4 (13%) in the conventional-therapy group. Relative risk of remission for the surgical group was 5.5 (95% confidence interval, 2.2-14.0). Surgical and conventional-therapy groups lost a mean (SD) of 20.7% (8.6%) and 1.7% (5.2%) of weight, respectively, at 2 years (P < .001). Remission of type 2 diabetes was related to weight loss (R2 = 0.46, P < .001) and lower baseline HbA1c levels (combined R2 = 0.52, P < .001). There were no serious complications in either group. Conclusions Participants randomized to surgical therapy were more likely to achieve remission of type 2 diabetes through greater weight loss. These results need to be confirmed in a larger, more diverse population and have long-term efficacy assessed. Trial Registration actr.org Identifier: ACTRN012605000159651 Author Affiliations: Centre for Obesity Research and Education (Drs Dixon, O’Brien, Chapman, Schachter, and Skinner and Mss Playfair and Anderson) and Department of Epidemiology and Preventive Medicine (Dr Bailey), Monash University, Melbourne, Australia; and Department of Medicine (AH/NH), University of Melbourne, Melbourne (Dr Proietto).

Viscio Law and The Obesity Law Center - Documents and Research That is the link to the NIH Criteria. It is over 40 with no co-morbs and 35 and over with one co-morb and NOT a significant co-morb like they say sometimes,when they'll ask for some deadly disease. Arthritis or depression can count as well. Gary

They're trying to scare you away.

They are supposed to, but I hear different stories on fills. Check out armytimes.com there's a section in there someplace on insurance. I'll try to find it and post the link

I'm sorry it should say WEIGHT LOSS SURGERY, not gastric bypass they actually called it "other radical surgeries" which is very annoying, but the study is pro for us. Finally. Sorry, it I couldn't edit the post

CNN REPORTS THE MOST COMPREHENSIVE PROOF THAT Gastric Bypass Lowers Risk of Death TIME MAGAZINE AUGUST 22, 2007 By Sora Song Whether one regards bariatric surgery — last-resort weight-loss operations such as gastric bypass and stomach stapling — as an essential treatment for obesity or as a failure of the fat person's will, the fact is, it works. Studies have shown that after surgery, patients often lose 50% or more of their excess weight — and keep it off — and symptoms of obesity-related conditions like diabetes, high blood pressure, high cholesterol and sleep apnea are improved or eliminated altogether. Now, two new studies in the New England Journal of Medicine (NEJM) show another long-term benefit: a lower risk of death. The larger of the two studies — the largest of its kind — led by researchers at the University of Utah School of Medicine, looked specifically at gastric bypass surgery, also known as Roux-en-Y gastric bypass, which accounts for 80% of all bariatric surgeries in the U.S. The operation involves creating a small walnut-size pouch at the top of the stomach, which is then stapled off and connected to the small intestine lower down than usual; the result is that patients can eat only an ounce of food at a time, and the food bypasses most of the stomach and the top part of the intestine, limiting the number of calories the body absorbs. In the Utah study, researchers compiled data on 15,850 severely obese people, half of whom had undergone gastric bypass surgery between 1984 and 2002, and half who were from the general population and had had no surgical intervention for obesity. Overall, researchers found, the surgery patients were 40% less likely to die from any cause during a mean 7 years of follow-up, compared with the obese controls. What's more, the mortality rate attributable to obesity-related disease was 52% lower on the whole in the surgery group: after gastric bypass, patients were 92% less likely to die from diabetes, 59% less likely to die from coronary artery disease, and 60% less likely to be killed by cancer. Results like these have got some doctors intrigued enough to start thinking about bariatric surgery as a treatment for conditions other than obesity —especially diabetes. A growing body of research suggests that the surgery may reverse the disease, a potential solution that could help some 20 million American diabetics. Though the current NEJM study did not specifically study the impact of bariatric surgery on diabetes, it did reveal a 92% reduced risk of death from the disease in surgery patients —findings that support what has been emerging in other experiments. "In more than 80% of patients who are severely obese and have diabetes and then have gastric bypass surgery, the diabetes is cured," says Ted Adams, professor of cardiovascular genetics at the University of Utah School of Medicine and lead author of the new study. "The interesting thing is that the resolution of diabetes happens within a few weeks following surgery, long before patients have lost their weight." Like some other researchers in the field, Adams believes that the surgery triggers other biological mechanisms, separate from weight loss — perhaps an interruption of a crucial biochemical pathway or a change in the release of certain hormones in the stomach or small intestine — that may have powerful effects on diabetes. "The gastric-bypass patient is really providing a source of intriguing research related to all kinds of disease treatment as well as weight gain and weight loss," says Adams. The second study, led by researchers at Gothenburg University in Sweden, involved 4,047 obese volunteers, 2,010 who underwent some form of bariatric surgery and 2,037 who received conventional obesity treatment, including lifestyle intervention, behavior modification or no treatment at all. Ten years after surgery, researchers report, the bariatric surgery patients had lost more weight and had a 24% lower risk of death than the comparison group. Though the overall number of subjects in this study is much smaller than the first, the results confirm general benefits of bariatric surgery, and gastric bypass in particular: after 10 years, bypass patients had maintained a 25% weight loss, compared to a 16% loss in patients who had stomach stapling, and 14% in those who underwent a banding procedure. In both studies, surgery patients had an overall lowered risk of death, but an interesting finding in the Utah study shows that these patients were 58% more likely to die from other causes, such as suicide and accidents. The authors speculate that as people lose weight and become more active, they also become more prone to accidents, which may up their risk of death. Surgery patients may also have pre-existing psychological problems — a history of abuse, perhaps — that can't be resolved by losing weight. "There have been some studies reporting that following bariatric surgery, some individuals may be more prone to chemical dependency, such as increased alcohol use," says Adams. "There's some speculation that certain addictive behaviors that are in place before the surgery — with food, for example — are transferred to alcohol or another addictive behavior." "Hopefully this research will stimulate additional evaluation of what the optimal approach is for evaluating candidates for this surgery," says Adams. "I think we should never lose track of the importance of individual evaluation of benefits and risks." Last year, an estimated 177,600 patients underwent bariatric surgery, a figure that's likely to grow as Americans get fatter and fatter. Though modern surgery techniques have become more sophisticated, less invasive and safer than in the past, the bariatric procedure still carries all the risks of any other operation. Patients have a .5% to 1% chance of death. The risk of gallstones goes up. Sometimes a second surgery is necessary. And all patients must be careful to make up for Vitamin and mineral deficiencies. The surgery isn't for everyone; current guidelines recommend it as a last resort, only for the morbidly obese who have a BMI of 40 and higher, or for the obese with a BMI of 35 and higher plus a serious weight-related illness like diabetes or hypertension. This should help. Gary Viscio Viscio Law and The Obesity Law Center - Welcome

BCBS of IL will pay when pressed They want you to feel defeated ashamed and embarrassed DONT

I've been getting flooded with questions on revisions. So, here's a short article I wrote for OAC, hope it helps. The weight loss surgery field has experienced exponential growth over the past four years. As a result, I find myself being asked more and more questions regarding post operative surgery. Be it plastic surgery, or a revision, the sheer numbers of post op patients is increasing the demand for these two types of post op procedures. In this article, we’ll talk solely about revisions. And that word, revision, gives rise to a number of included terms such as failed surgery, non compliance and revision to a new procedure. Revision, defined, is to change or modify. For our purposes, to change or modify a prior bariatric surgery. There are several areas where revisions can arise. A patient will be dealing with either a revision of a failed bariatric procedure, or a revision to a new type of procedure not approved or even in existence at the time of the original surgery. In either case the question is the same. Will my insurance carrier cover a revision? Simple question, but a not so simple response. As we all know insurance companies seem to make decisions by throwing darts at a dartboard. So it’s only natural to assume that a carrier will have different responses for different individuals from different states. To begin, a request for a revision based upon a failed prior bariatric surgery is going to immediately invoke a response from most insurance carriers questioning whether the prior surgery actually failed, or the patient was simply not compliant with the requirements of the first surgery. In other words eating past the pouch or band. A revision from a prior procedure to a new type of procedure is going to receive similar questions along with the additional question of why the patient is seeking to change from a RNY to LAPBAND or DS. Before you make this type of request it is imperative that you and your surgeon are on the same page. He or She should be aware of the exact need for the surgery, as well as your compliance issues during the original procedure. Never wait for the insurance company to ask the question. Answer it when your surgeon submits the request for authorization. If the your going the pouch has stretched, staple line failed, band slipped or bypass simply hasn’t worked you must have the pre-op testing to prove these allegations. Whether an MRI, CT Scan or Endoscopy you should have the results before you apply for certification. Likewise, you should provide your surgeon with a general description of your compliance over the years, consisting of a diet and exercise history. Chances are your BMI has been low while at times and you no longer have any significant co-morbidities. In this case your going to make sure that the carrier knows that if the revision is not granted, it will only be a short matter of time before your BMI climbs even higher and your co-morbidities return. If your request involves a new type of surgery, perhaps one that didn’t exist when you had your original surgery, make sure the reasons why this surgery is right for you are included in the request for surgery. These pre-emptive strikes just may get you the approval you seek by answering the insurance company’s questions before they’re asked. I know what you’re thinking. Supposed my insurance company does not or no longer covers bariatric or weight loss surgery. Well, in that situation you’re going to argue two things. First, that weight loss surgery should be a covered expense because it is used to treat co-morbidities in addition to obesity, such as diabetes or hypertension. And second, that this is a request to correct a failed procedure that may cause significant problems in the near future and as such it is not for obesity or weight loss. A tougher argument but one that has been made successfully. So remember, like your request for your original surgery, you must document your claims. And, of course, never quit. Gary Viscio Viscio Law and The Obesity Law Center - Welcome RNY 7/1/03 -166lbs

hard to say state by state. i deal more with BCBS and CIGNA if that helps.GHI and aetna usually cover the band

There's a new band coming out. Ethicon purchased a swiss company that made a swiss band. It is supposed to be out in the next few months. What does it mean. Just that you'll have more choices. (as long as insurance covers the new band with no problems) I'll try to find a link Gary

let me know if you want anything added:)

Just a quick announcement, if you visit our new website, http://obesitylawyers.squarespace.com/ You'll see an area for journaling. In addition to adding documents, research reports and sample appeals, we're also adding podcasts and videocasts. These will be topical and focus on appeals, denials, as well as nutrition, exercise. We have interviews scheduled with three bariatric surgeons, a personal trainner and nutritionist, as well as clients and patients alike. All free to give you a better understanding of these areas. Be well. Gary Viscio www.obesitylawyers.com

Jeremy Gentles and I are pleased to announce that two new forums, created by us, with your assistance, are now open and ready for your use. The Exercise and Diet forum caters to anyone pre or post op, and is hosted by Fitness expert Jeremy Gentles. Get free advice. Peer support. GET BACK ON TRACK post op. Please join us at http://www.obesityhelp.com/forums/fitness Also, I have created an Insurance Forum that I believe anyone will find the greatest wealth of information, peer support, sample appeals and overall how to information provided freely on the web. Bariatric and Plastic Surgery. Get them approved now. Please join us at http://obesityhelp.com/forums/insurance Thank you all for your support. Gary Viscio, Esq. RNY 7/1/03 -160lbs www.obesitylawyers.com

Jeremy Gentles and I are pleased to announce that two new forums, created by us, with your assistance, are now open and ready for your use. The Exercise and Diet forum caters to anyone pre or post op, and is hosted by Fitness expert Jeremy Gentles. Get free advice. Peer support. GET BACK ON TRACK post op. Please join us at http://www.obesityhelp.com/forums/fitness Also, I have created an Insurance Forum that I believe anyone will find the greatest wealth of information, peer support, sample appeals and overall how to information provided freely on the web. Bariatric and Plastic Surgery. Get them approved now. Please join us at http://obesityhelp.com/forums/insurance Thank you all for your support. Gary Viscio, Esq. RNY 7/1/03 -160lbs www.obesitylawyers.com

The fee is not unusual. Many offices charge this fee as an administrative fee for paperwork, nutrition counseling etc. Also just in case your insurance company doesn't pay him for his consultation. That other doc you spoke of, beware of docs who in the past could not get the band covered so they billed this as a bypass. That is a problem on the Surgeon's part and could come back to haunt you. Such as when you go to get a fill or have a complication and now the carrier thinks you were part of the fraud. If the money is an issue ask them to please waive it. THey'll be making more than that once your done and happy.

Covering the bypass and not the band is actually common, and there are two reasons. One is that the plan or employer just renews every year and no one really looks into it because they just don't care, or the other is that they do it intentionally because they know many people don't want to be re-arranged internally. About two years ago the carriers started covering open bypass instead of lap and the word was they were going to make that more widespread. They said it was safer but the real reason was because most people were now applying for it lap and not open. Open scared them away. My feeling. Nothing is done on accident. Good luck Gary

The NIH Criteria is 35 with one or more co-morbs or 40 with none. You should be ok around 35. Nothing ventured nothing gained. Best of luck

If you call me I can assist you. Unfortunately I see alot of these posts about one attorney or another and in many cases it turns out to be someone who just wants to bash us or compete against us. So, since I have no idea who you are, I would ask that you give me a call, or email me, and we can assist you. Additionally, even people who don't use lawyers will tell you that insurance carriers tell you one story or another. We have proof of filing of our appeals and work with all carriers. The diet history is normally something that can easily be overcome. If you do not contact me I'm going to have to assume this is just another flamming post against our firm. If this is a real post then I truly apologize if you felt neglected. If you email me today, I'll send you my cell phone to call this weekend. I waited for 6 months to have the surgery because of a problem with my surgeon's office. I hated it. It was torture. BUT, I never had to worry as to whether I would be approved or not. That is something I could not imagine. Honestly. I was brought up as an attorney handling litigation. Negligence and that sort. My fees for appeals that top at 750 and where we often workout any type of payment plan and sometimes handle cases for free is really very small in comparison to what the other fields could bring in. But I do hate that these companies make you jump through these hoops. And, I want, if my children ever decide to become lawyers (hope not ) that I can leave them something they can be proud of, and feel like they accomplish something, not just go around and sue someone. Call me. Gary Viscio www.obesitylawyers.com rny 7/1/03 -165lbs

You're fine. If they deny, just appeal, the State of NY is very good to deal with.

Medicare Backs Obesity Surgery U.S. to Pay for Three Types of Stomach-Shrinking Operations By Rob Stein Washington Post Staff Writer Wednesday, February 22, 2006; A08 Medicare endorsed three types of stomach-shrinking surgery yesterday, saying the controversial procedures can offer Americans safe and effective ways to treat obesity. The announcement was seen as a boost for the popular operations, known as bariatric surgery, which had come under a cloud in recent years because of concerns about their safety. "In the right hands, bariatric surgery can benefit patients," said Steve Phurrough of the Centers for Medicare and Medicaid Services, which sets policy for the federal health program. Under the new rules, Medicare will pay for the surgery for obese patients who are suffering from other health problems related to their weight, as long as they undergo the procedure at centers that have been certified as well qualified by the American College of Surgeons or the American Society of Bariatric Surgery. Although some insurers do not cover it, the number of people undergoing the procedures, which cost $25,000 to $40,000, has increased rapidly, jumping from about 16,000 operations in 1992 to an estimated 170,000 in 2005. The decision was hailed by proponents of the surgery, who see it as providing one of the only effective options for Americans struggling with obesity. "This is very positive for millions of Americans," said Morgan Downey of the American Obesity Association. The decision could also open the door for Medicare to cover other treatments for obesity, such as nutritional counseling, physician-supervised weight-loss programs and perhaps weight-loss drugs, Downey said. "We've been waiting to see how they responded to the surgical side. This will give us a cue as to where to go next," Downey said. "I think we'll start seeing Medicare start looking at other interventions." Because private health insurers often follow Medicare's lead, several experts predicted the decision would have broader implications. "The health system in general has largely ignored paying for weight-loss interventions up to this point. This is going to help them reconsider that," Downey said. But critics denounced the decision, saying the procedures are dangerous. "The decision to continue coverage is ill-advised and will expose many people, especially the elderly, to high risk," said Paul Ernsberger of the Case Western Reserve School of Medicine. "There may be some benefits, but there are alternative safe and effective treatments for every obesity-related condition." With one-third of Americans obese, public health experts have become increasingly concerned about the long-term impact on the nation's health. Despite numerous efforts to get Americans to eat better and exercise more, many people find it impossible to lose significant amounts of weight and keep it off, especially those who are extremely overweight. Surgeons perform several variations, but all involve sharply restricting the size of the stomach. The procedures can enable people to lose hundreds of pounds, alleviating disabilities and preventing, even sometimes reversing, serious health problems such as diabetes and high blood pressure. But the rapid increase in the surgeries has raised alarm about their safety, especially when performed by inexperienced surgeons at centers that offer limited follow-up care. Patients are prone to life-threatening complications, including bleeding, blood clots, leakages and infections. Even those with no serious complications can experience unpleasant side effects, including nausea, vomiting and diarrhea. As a result, they require intensive counseling and monitoring. The concerns have led a number of large insurers to refuse to cover the procedures. In October, two large new studies concluded that the surgery is much riskier than had been thought, with patients facing a far greater chance of being hospitalized and dying after the procedures. The following month, the Centers for Medicare and Medicaid Services recommended the program only pay for the operations for the disabled, saying they were too risky for the elderly. But after further analysis indicated that the procedures could be safe for the elderly as long as they are performed by experienced surgeons, the agency decided to approve coverage for them as well, Phurrough said. The coverage will be limited to three of the most commonly performed procedures: Roux-en-Y gastric bypass, gastric banding and biliopancreatic diversion with a duodenal switch, Phurrough said. Best of luck and health. Gary Viscio www.obesitylawyers.com

Our work with Harrahs ihasw now officially paid off. Please check this link and read the chain reaction that has begun. We worked with Gina and Harrahs for over a year and were able to work with her company very well. WLS is now a covered benefit in 2006. There is now proof and you can use this when you seek your surgery. http://obesityhelp.com/forums/LA/postdetail/7000.html?vc=0 The Only Law FIrm on the Obesity Help Advisory Team Coverage Negotiator for Medtronics IGS The Only Attorney who has been able to single handedly change an employees insurance coverage. When they need to call, there is only one call to make Gary J. Viscio www.obesitylawyers.com -171 7/1/03