VSG CPT CODE - Federal BCBS

[babygirlinokc 0]

:biggrin0:Hi my name is babygirlinokc,

I had a lap band done on 04-04-08. Did not work for me at all. So, 05-20-09 I had the lap band removed and the vsg done. Day and night!!! I love my sleeve. It totally ROCKS!!!

The surgeon that did my sleeve was an out of network provider for Federal BCBS. Doctor told me that I should do self pay. Then Federal BCBS would reimburse me. They said the reimbursement would not be the full amount that I paid for the surgery (12,500.00) but some of it should come back.

Well on the Obesity Help web site there were numerous amount of vsgers claimed Federal BCBS paid for their vsg the full amount. So, that is where I'm at right now. The claim that my doctor turned in had a cpt code of 43659, which Federal BCBS denied.

:biggrin2: They do cover 43843. So, I asked my doctor if he could resubmit my claim with 43843. After researching the

43843 he said yes they would resubmit my claim with the cpt code 43843.

Is anyone out there who had theirs covered at least most of it, by Federal BCBS?

Thanks for responding!!! :wink:

[lapfish 0]

I have Federal BC BS and was told that it pays 85% as long as it is in network. They are going to use the 43843 CPT code for mine as well. I go for my consult on Tuesday. I should be almost at my Catastrophic cap, which would put it at 100% covered! :001_tt2: Don't know what it would be though if you were out of network. You can check on FEPblue.org though to see what it would be. Oh, I have standard option too. You have to know whether it is Standard or Basic. HTH

Rebekah

[*susan* 1,709]

I did not use insurance, so can not help you there. I just wanted to pop in and welcome both of you to the forums, we are glad to have you join our family!

[Malaika 50]

I'm with Susan - my insurance didn't cover it either ... but also wanted to welcome you both to the forum!

[babygirlinokc 0]

I have Federal BC BS and was told that it pays 85% as long as it is in network. They are going to use the 43843 CPT code for mine as well. I go for my consult on Tuesday. I should be almost at my Catastrophic cap, which would put it at 100% covered! :biggrin0: Don't know what it would be though if you were out of network. You can check on FEPblue.org though to see what it would be. Oh, I have standard option too. You have to know whether it is Standard or Basic. HTH

Rebekah

Hi there,

So glad that you responded. I too have Standard Option. I think it stated in the bcbs fep policy that 70% would be paid for the out of network providers. I am praying that I do get approved. My doctor already sent out the claim with the cpt code of 43843. Thanks for sharing. Blessings to you.

babygirlinokc

[babygirlinokc 0]

I did not use insurance, so can not help you there. I just wanted to pop in and welcome both of you to the forums, we are glad to have you join our family!

Susan,

Thanks so much for the welcome!

[babygirlinokc 0]

I'm with Susan - my insurance didn't cover it either ... but also wanted to welcome you both to the forum!

Hi VegasAngel,

Thanks so much for the welcome. I have a brother who lives in Boulder City!!! Wish I was there right now visiting with him..........

[babygirlinokc 0]

I have Federal BC BS and was told that it pays 85% as long as it is in network. They are going to use the 43843 CPT code for mine as well. I go for my consult on Tuesday. I should be almost at my Catastrophic cap, which would put it at 100% covered! :biggrin0: Don't know what it would be though if you were out of network. You can check on FEPblue.org though to see what it would be. Oh, I have standard option too. You have to know whether it is Standard or Basic. HTH

Rebekah

Rebekah,

I have a dumb question. What do you mean about having a Catastrophic cap?

[babygirlinokc 0]

Hi there,

So glad that you responded. I too have Standard Option. I think it stated in the bcbs fep policy that 70% would be paid for the out of network providers. I am praying that I do get approved. My doctor already sent out the claim with the cpt code of 43843. Thanks for sharing. Blessings to you.

babygirlinokc

Hi Rebekah,

How did your 1st consultation go? I bet you are excited. Hope it all went well for you. I will let you know when I find out about my claim. Have a great rest of the week.....

babygirlinokc

[nouveau-debut 0]

I have Fed BCBS also. I was told that they would cover 100% of the sleeve as long as I could prove it was medically necessary (I have Basic). I haven't had surgery yet, but you have me thinking I should ask some more questions. I know that Norman and Baptist hospitals are considered Blue Distinction. Thanks for the info!

[MacMadame 81]

There are a bunch of people on OH who used BCBS Fed for their VSG. However, an individual company may have a WLS exclusion that would override that coverage.

[cajun 46]

I've been doing a lot of research on VSG and found great news coming out of the Second Internationa Consensus Summit for Sleeve Gastrectomy in March, 2009. "During the consensus part, the audience responded that there was enough evidence published to support the use of SG as a primary procedure to treat morbid obesity and indicated that it is on par with adjustable gastric banding and Roux- en-Y gastric bypass, with a yes vote at 77%. CONCLUSION: SG for morbid obesity is very promising as a primary operation."

*The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009. (2009) Q-Sensei

Another article stated that: "There are signs of progress with multiple insurance companies. It should be expected that in 2010 sleeve gastrectomy have its own code and a formal acceptance."

http://bariatrictimes.com/2009/06/18/laparoscopic-sleeve-gastrectomy/

YIPPEE

[babygirlinokc 0]

Thanks cajun, I appreciate the info.

[uncertainty 0]

Hang in there. The AMA has assigned a CPT code for LSG (laparoscopic sleeve gastrectomy) to be public 11/1/09, effective 1/1/10. We are turning the corner on sleeve gastrectomy......the best option. I paid cash and would do it all over again, but my life has changed and there will be no need to further procedures. Lost 112 lbs.

By the way, United Health Care issued a National Coverage Decision on LSG and are now covering as of 10/1/09. This does not necessarily mean the local United affiate that administers your plan will cover, but will pay attention when United Parent has issued coverage statement.:cursing:

[*susan* 1,709]

Hello uncertainty, and welcome to our forums! Wow, 112 pounds, you have done great. How long ago did you have your surgery? I would love it if you would share your story with our members in the "Tell Your Story" forum.