ChampVA

[flrosie 154]

I've been reading through this forum's posts and I don't see anything current about ChampVA. Since I wasted four months going through the hoops my surgeon's office put me through because they didn't understand what ChampVA wanted, I'd like to post the information that may help others. This is directly from a current letter (February 2013) from ChampVA.

In most cases WLS does not require preauthorization. Coverage is provided for lapband (Lapband brand, btw), vertical banded gastroplasty, gastroplasty (stomach stapling), Roux-en-Y, and revision of gastric restrictive procedure.

"Surgical correction of morbid obesity benefits may be extended only when one of the following conditions is met: 1) Patient's BMI is over 40 or, 2) BMI over 35 with serious medical conditions exacerbated or caused by obesity or, 3) Second surgery (takedown) due to complications of previous surgical correction."

Billing for surgical treatment of morbid obesity must be accompanied by medical documentation, which includes:

• At least 18 years old
  
• Documented attempts (at least 2) of failed non-surgical medical treatment for obesity (Weight Watchers, Jenny Craig, or similar plans are acceptable as long as you have at least monthly clinical encounters with you physician that documents weight loss efforts).
  
• BMI greater than or equal to 40 or, BMI 35 - 39.9 with one clinically significant comorbidity (cardiovascuar disease, Type 2 diabetes, sleep apnea, hypertension, etc.)
  

Bottom line: You do NOT have to wait for approval for surgery provided you have at least two documented attempts at physician monitored weight loss and a BMI >40 or <40 with co-morbidities.

When I spoke with ChampVA directly (which I should have done four months earlier than I did), I was told the surgeon must submit this documentation with the first billing. There is no approval process. If you submit the proof they will pay according to their benefits (currently 25% of allowed amount). If the surgeon's office submits documentation asking for approval, they will get the same letter I (and the surgeon's office) received stating pre-authorization is not required nor will it be granted or presumed from the documentation the surgeon's office provides. ChampVA will only review the information when it is submitted with the first bill.

I'd also like to say that some surgeons require the nutritionist, psych eval, and other medical tests for their own edification in deciding if you are a good candidate for surgery but that is not the requirement of ChampVA.

Always, always, always, check with your insurance company yourself and first (wish I had). Document what you were told, request written clarification and keep that documentation safe in the event there is a problem later down the road. It is not uncommon for two different insurance reps to provide different information from the same question. If need be, ask until you get a consensus and there is written documentation to support what you've been told. Then, before you make a date for surgery, make sure you absolutely know, with documented proof in your own hands that you give to the insurance coordinator at your surgeon's office, that you have complied with the three simple rules above.

Hope this helps.

[smongo 0]

I've been reading through this forum's posts and I don't see anything current about ChampVA. Since I wasted four months going through the hoops my surgeon's office put me through because they didn't understand what ChampVA wanted' date=' I'd like to post the information that may help others. This is directly from a current letter (February 2013) from ChampVA.

In most cases WLS does not require preauthorization. Coverage is provided for lapband (Lapband brand, btw), vertical banded gastroplasty, gastroplasty (stomach stapling), Roux-en-Y, and revision of gastric restrictive procedure.

"Surgical correction of morbid obesity benefits may be extended only when one of the following conditions is met: 1) Patient's BMI is over 40 or, 2) BMI over 35 with serious medical conditions exacerbated or caused by obesity or, 3) Second surgery (takedown) due to complications of previous surgical correction."

Billing for surgical treatment of morbid obesity must be accompanied by medical documentation, which includes:

[*']At least 18 years old

[*]Documented attempts (at least 2) of failed non-surgical medical treatment for obesity (Weight Watchers, Jenny Craig, or similar plans are acceptable as long as you have at least monthly clinical encounters with you physician that documents weight loss efforts).

[*]BMI greater than or equal to 40 or, BMI 35 - 39.9 with one clinically significant comorbidity (cardiovascuar disease, Type 2 diabetes, sleep apnea, hypertension, etc.)

Bottom line: You do NOT have to wait for approval for surgery provided you have at least two documented attempts at physician monitored weight loss and a BMI >40 or <40 with co-morbidities.

When I spoke with ChampVA directly (which I should have done four months earlier than I did), I was told the surgeon must submit this documentation with the first billing. There is no approval process. If you submit the proof they will pay according to their benefits (currently 25% of allowed amount). If the surgeon's office submits documentation asking for approval, they will get the same letter I (and the surgeon's office) received stating pre-authorization is not required nor will it be granted or presumed from the documentation the surgeon's office provides. ChampVA will only review the information when it is submitted with the first bill.

I'd also like to say that some surgeons require the nutritionist, psych eval, and other medical tests for their own edification in deciding if you are a good candidate for surgery but that is not the requirement of ChampVA.

Always, always, always, check with your insurance company yourself and first (wish I had). Document what you were told, request written clarification and keep that documentation safe in the event there is a problem later down the road. It is not uncommon for two different insurance reps to provide different information from the same question. If need be, ask until you get a consensus and there is written documentation to support what you've been told. Then, before you make a date for surgery, make sure you absolutely know, with documented proof in your own hands that you give to the insurance coordinator at your surgeon's office, that you have complied with the three simple rules above.

Hope this helps.