Went in for RNY, changed to Sleeve midstream

[cjradio 0]

Wanted to solicit any suggestions from everyone here.

I was preapproved through all the hoops to have the RNY. When i went in to have the surgery, my surgery found tons of adhesions from a previous surgery many moons ago and was unable to do the RNY. We had discussed this ahead of time and the Lapband was not appropriate for me for numerous reasons. She did the sleeve.

My insurance company denied it of course. But after they appealed it and they have denied it again stating it was unproven. They said I could submit a second appeal if I wished.

The issue I have is that my Doctor did not know until she got inside me that she could not do anything. So had she stopped right there, closed me up, i would still have had to stay over night, pay the cost of the surgery suite, anesthesia, etc etc. Instead, I got a positive outcome and have lost 70+ lbs since January.

I am working with my (most excellent and wonderful) surgeon about this.

Any thoughts you all have would be most welcome!!

[MacMadame 81]

Check out my profile on OH for some links about the sleeve including some 5 year results. That can help with the "unproven" angle. I'm "MacMadame" on there too.

[cjradio 0]

Doh... Took me a few days to realise the replies were in my spam... got it changed and have checked out the documents... Thanks so much!

[Headhunter 0]

Hmmm.....Interesting.

Looks like the Sleeve still hasn't hit mainstream WLS yet, at least far as the insurance goes.

I'm kind of surprised, considering that the Track Record has been so good thus far, and the band has gotten "iffier" as time goes on, in terms of complications.

But, it did take the Band a while before it made mainstream as well.

HH

[*susan* 1,709]

HH, I am surprised by this as well. I don't know, maybe they are waiting for more long term statistics to come out? Perhaps the insurance industry feels it jumped the gun by approving the band so quickly, considering all the problems people are now having that are two or more years out.

[MacMadame 81]

I think they are looking for more long-term (5 years out) studies in peer reviewed journals.

And to avoid having to pay for anything they can avoid for as long as possible, of course.

[*susan* 1,709]

I think your last sentence hit it pretty close. They want to collect as much of our money as possible and have to pay out as little as possible.

[Headhunter 0]

I'd agree with that.

One thing I would LOVE to do some time is to sit down with a member of management from an insurance company, and have a discussion about stuff like this; how they make their decisions about what to cover, what to refuse, etc. And, where they get their stats and how they deal with adverse event reporting, etc.

I know that there are Insurance industry assosciations and statisticians and actuaries, etc, that determine all of this, but the real outcome data is so hard to obtain and compile. Sometimes I wonder why they stall on so many things, yet other times I wonder WHY they can be so liberal with what they WILL pay for.

It's an interesting business, not one I would like to be a part of.....

HH

[wayupnorth 1]

I to was scheduled for a RNY but because of adhesion was converted to a sleeve. My insurance company did approve this ahead of time.

[cajun 46]

That's a possibility...never crossed my mind. They have probably taken a big hit on band revisions.

[bostermax 0]

I was also keen to know what the points are for. At the moment it?s just about bragging rights, but down the road they are looking into special offers to trade for points or making donations to charity. I wondered what orphans will do with the Foursquare points. Let?s just say it?s not all figured out yet.

[Tracy46545 6]

um....boostermax....

uhhhh WHAT???????

[Felecia 0]

I had to appeal my insurance denial twice before they agreed to cover the Sleeve. My insurance company agreed to cover the RNY or the band and based there denial on the Sleeve still bieg an "investigational procedure" so I looked up clinical trials and printed off about 25 still in progress on the band and RNY also I stated my reasons for choosing the Sleeve for long term health, I argued the expense of malabsoption issues that can come with the RNY or future intestinal blockage issues. I think you saved them money long term but these insurance companies don't make it easy. I also filed a complaint with the insurance commisioner in my state and in my appeal letter let the insurance company know that... maybe that helped

But I think what really sent them over to approval was I had my surgeon (after much begging) call and speak with there "expert DR." who was in charge of the appeals at the board level. Hope this mess gets figured out for you.