Verbiage to use for insurance appeal?

[brittu 42]

Hi there!

I'm working on my insurance appeal letter. I have a lap band that's failed (slip plus pouch dilation) and want to revise it to a VSG. I was denied on three counts. First, the removal of the lap band was denied because it wasn't deemed medically necessary. I figure maybe the insurance clerk who decided this ought to come and offer to hold my hair during the 4-8 hours per week I spend bent over the toilet sliming :-). They denied revision to VSG claiming that VSG was investigational. That makes no sense because I have Federal BCBS who have been covering VSG since 2008 and I just think that's an error on the local administrator's side. And they also denied it because I'm no longer > 35 BMI - well "no duh" my lap band helped me lose weight before it slipped.

I can fight the lap band removal and "not morbidly obese enough" part pretty well and have written that part of the letter. But the part I'm struggling with is any additional documentation to fight the claim that VSG is investigational. So...

Does anyone have verbiage from their appeal that they can share? Or a pointer to a published medical opinion or study that I can point to?

Any help appreciated!

Britt

(Sorry for the other posts if you also frequent other boards - I'm trying to cast a wide net.)

[WASaBubbleButt 41]

Hi there!

I'm working on my insurance appeal letter. I have a lap band that's failed (slip plus pouch dilation) and want to revise it to a VSG. I was denied on three counts. First, the removal of the lap band was denied because it wasn't deemed medically necessary. I figure maybe the insurance clerk who decided this ought to come and offer to hold my hair during the 4-8 hours per week I spend bent over the toilet sliming :-). They denied revision to VSG claiming that VSG was investigational. That makes no sense because I have Federal BCBS who have been covering VSG since 2008 and I just think that's an error on the local administrator's side. And they also denied it because I'm no longer > 35 BMI - well "no duh" my lap band helped me lose weight before it slipped.

I can fight the lap band removal and "not morbidly obese enough" part pretty well and have written that part of the letter. But the part I'm struggling with is any additional documentation to fight the claim that VSG is investigational. So...

Does anyone have verbiage from their appeal that they can share? Or a pointer to a published medical opinion or study that I can point to?

Any help appreciated!

Britt

(Sorry for the other posts if you also frequent other boards - I'm trying to cast a wide net.)

The first two issues should be easy to resolve. It's not up to a clerk to decide if something is medically necessary. Fed BC/BS most certainly does pay for sleeve.

The BMI...that one they may just get you on. If their requirements are that you be a certain BMI they have every right to deny you. :laugh0:( Not right and not fair, but they get to make the rules.

I would explain that the Standard of Care is such that you should do a revision at the same time as the band removal when possible. Now, if you have a slip it may not be possible to do a revision at the same time as band removal. If your stomach is swollen it is not wise to do a sleeve until it heals. The problem is, then you really will be in a pinch because it will no longer be considered a revision to get a sleeve but it will be treated as your original surgery. WLS for an obese person and you *will* have to meet all the requirements.

[ahchancey 0]

I have Federal BCBS and they paid for me to have a revision a gastric bypass to a VSG. I to had a problem with vomiting, the opening was narrowed and not allowing food to go through. I think when you appeal the decision is made by a different clerk. Dont give up. They dont always consider VSG investigational, my was approved the first time.:laugh0:

[brittu 42]

Hi WASA,

What's funny is that they didn't deny the VSG for the BMI reason, the denial letter states only that it's investigational. It's the removal of the lap band that they denied because of the BMI. Isn't that funny? Like no matter how much you're suffering you have to regain the weight AND vomit and not be able to eat to get the danged thing out. Or be lucky enought to have a slip before you lost much weight :-). Even if they brought out the BMI argument for the VSG I'd still fight them - I had a gastric restrictive procedure and it needs to be fixed so that I have gastric restriction again. My original surgery was covered and I met all the requirements so it seems like a continuation to me, not something new. If I went and asked for breast implants I'd be denied. But if I had breast cancer and a mastectomy and a year later asked for breast implants I'd be covered. They wouldn't deny me because I no longer had cancer.

ahchancey,

Would you be willing to share the doctor and/or state in which you had the revision? Part of my argument includes a list of all the doctors I've found with Fed BCBS patients who were approved for VSG. I've been calling the local plan admins in those states and confirming the coverage. So far, everyone says no problem. Of course my state admin said no problem too. They actually have two separate local BCBS companies doing the admin here and I think that's part of the problem. The group that does the customer service told me it was fine but the company that handles the pre-certs says it wasnt' and the other company was wrong.

Sigh... Almost every day I think just screw it and I'll go see Aceves and pay for it myself. But now I've almost got the letter done, just need a blurb or two on why VSG is safe and mainstream and I'll send it off. Then I'm done and I'll either get it or book my trip to Mexicali. If I won the lotter I'd just book my trip and get goin' :-).

Britt

[ahchancey 0]

Sure anything to help. By the way my BMI was only 35 to start with for the revision. The Dr. I used is Vadim Sherman of Baylor College of Medicine in Houston, Tx.

[MacMadame 81]

I want to know how you revise a bypass to a sleeve! I've been dying to know this ever since the topic first came up on another board.

[WASaBubbleButt 41]

I want to know how you revise a bypass to a sleeve! I've been dying to know this ever since the topic first came up on another board.

You wouldn't, but theoretically you can. If someone fails bypass they aren't going to do much better with a sleeve but sometimes they can be revised to DS and of course, the sleeve is the first part of DS.

They basically take down RNY and do DS from there. Nothing is removed in bypass, a lot of people think the bypassed intestine is removed and it isn't. It's bypassed.

One of the problems/concerns seems to be the pyloris valve. In bypass it is bypassed or stapled off. It takes awhile for it to wake up again for lack of better terminology.

Dr. Husted in Kentucky (I think) is one of the few surgeons that can take down bypass and revise to DS. That guy is a true true true revision surgeon. His name is being passed around a great deal because of a new technique he came up with. Kinda like a 5th WLS type but I haven't researched it so I know nothing about it. I really should learn more about it.

[MacMadame 81]

I believe you are talking about the Vertigo and I do NOT think it's a good idea. They take out the Omentectomy during surgery. Supposedly this speeds up your metabolism, but it's all theory with no studies to back it up. Also, your Omentectomy shrinks when you lose weight. So it's just adding risk without adding benefit, IMO.

They also do an Ileal Transposition -- which also claims to speed up metabolism "without malabsorption". However, not having our intestines changed is a plus of the sleeve. Plus, while the studies on mice and Ileal Transposition are promising, jumping from mice to humans at this point in time is very premature IMO.

Not only that, he is charging as much as a DS for this operation even though it's much less complicated and has less OR time.

I have to say, I am very underwhelmed with Dr. Husted because of his pushing of the Vertigo and the DS.

[WASaBubbleButt 41]

I believe you are talking about the Vertigo and I do NOT think it's a good idea. They take out the Omentectomy during surgery. Supposedly this speeds up your metabolism, but it's all theory with no studies to back it up. Also, your Omentectomy shrinks when you lose weight. So it's just adding risk without adding benefit, IMO.

They also do an Ileal Transposition -- which also claims to speed up metabolism "without malabsorption". However, not having our intestines changed is a plus of the sleeve. Plus, while the studies on mice and Ileal Transposition are promising, jumping from mice to humans at this point in time is very premature IMO.

Not only that, he is charging as much as a DS for this operation even though it's much less complicated and has less OR time.

I have to say, I am very underwhelmed with Dr. Husted because of his pushing of the Vertigo and the DS.

I remember a whirlwind of drama on the DS boards over his nurse going there and pushing this new procedure but I didn't read it. I just saw mention of it.

I don't know anything about the procedure other than what you write above, I haven't researched it yet but Husted does have a pretty good track record with taking down RNY and revising to DS. Not many surgeons can do it.

How much does he charge for this procedure? Do you know? Is he doing it on newbie types or revision patients?

[Malaika 50]

What exactly is a DS? I know what it stands for, I just don't know what type of surgery it is.:tongue_smilie:

[WASaBubbleButt 41]

What exactly is a DS? I know what it stands for, I just don't know what type of surgery it is.:tongue_smilie:

It's the big mega procedure, Duodenal Switch. Mega bypassed intestine.

[MacMadame 81]

How much does he charge for this procedure? Do you know? Is he doing it on newbie types or revision patients?

He charges as much as a DS! I'm sorry, but that's crazy.

He seems to push it on people who come to him for a sleeve -- which means mostly virgin WSL people.

Some surgeons are all about cutting and I think he's one of them. Cut first, think later. :001_tt2: That doesn't mean he's not skilled at cutting. But I want a surgeon who also thinks. :thumbup: