Unapproved for Sleeve - Ready to CRY

[jsm 1]

CareFirst BlueCross BlueShield of MD approves the following:

• Adjustable gastric banding (e.g. Lap BAND?)
  
• Gastric bypass
  
• Gastric stapling
  
• Biliopancreatic bypass with duodenal switch
  
• Sleeve gastrectomy, performed either as a stand-alone restrictive procedure, or as a first stage procedure of a planned biliopancreatic bypass with duodenal switch for patients with a BMI exceeding 50
  

Since my BMI is 41, I don't meet the VSG qualifications, but I do qualify for gastric banding or bypass. It truly makes no sense that VGS will be approved as standalone for BMI > 50. If my BMI was > 50, I would be approved for Gastric Band, Gastric Bypass or VSG,

I have submitted my appeal with tons of documentation on the latest VSG studies, and my surgeon has request a peer to peer review with the Medical Director of Appeals. Hopefully they will get the message.

I do not know what the outcome will be, but I will not go down without a fight. With that said, I'm afraid I will be forced to cave in to RNY. I need to start my weight loss process asap. I can barely fit into any of my clothes, and I refuse to go out and purchase larger sizes.

I am still trying to keep my positive attitude, but I feel myself wearing down.

I'm so thankful for all the support everyone has provided.

Hugs to All,

JoAnne

Edited October 17, 2009 by jsm

[Quest2lose 0]

OK.....I work for CareFirst BlueCross BlueShield. I was told by our member services that the Sleeve was covered. I also looked at a copy of our Medical Policy, which states:

Sleeve gastrectomy, performed either as a stand-alone restrictive procedure, or as a first stage procedure of a planned biliopancreatic bypass with duodenal switch for patients with a BMI exceeding 50

So, assumed that since I was just having a stand-alone restrictive procedure, there was no BMI associated with that. However, it appears that CF will only cover the sleeve for patients exceeding 50. This makes no sense to me.

I'm ready to throw-up and cry!

I do not want the bypass. If I appeal, my date of 11/10 is out the window. :cursing:

I went through the same issue as you. Very few insurance companies approve the sleeve because its's coded "experimental". After reading several blogs and doing a little research, I found an affordable self pay solution in TJ, Mexico and I couldn't be any happier. Dr. Almanza was a GodSend, you may want to check him out.

[jsm 1]

Well, my appeal has been received, and they have 15 days to respond. I do know that my surgeon will be doing a peer to peer appeal for me too. I have already started my pre-op testing (sonagram, chest x-ray, barium swallow and 15 tubes of blood yesterday). I just wish I had the final decision so I could plan my next steps. I could probably swing $5,000, but $9,500 plus air would be out of the question right now. The sad thing is my surgeon is supportive of the sleeve surgery.

I'm still trying to keep that positive energy flowing. :drool5: Has anyone had their surgeon go to battle for them with the insurance company? If so, what was the outcome?

Hugs,

JoAnne

[Chancie 65]

JoAnn-

I don't have any advice or information- just wanted to let you know I'm thinking of you! It really is a shame with these insurance companies... don't they realize this is like preventive medicin? All the comorbidies that go along with extra weight........ It's frustrating!!

Keep up the positive attitude! I'm sure there will be someone to come along and answer your questions.

[*susan* 1,709]

I am pulling for you and have my fingers and toes all crossed. Keep us posted.

[Sandy Johnson 15]

Keep the faith! Just want to point out that it's a good sign that your doctor is supportive. Hopefully he will go to bat for you and do a peer to peer for you! Keeping my fingers crossed!

[jsm 1]

Thanks Chancie, Susan, Sandy and to all that have replied or just feel my frustration. This is why I love this forum. Everyone is so caring and supportive. I feel like everyone is part of my family.

Your good thoughts and energy keep me going.

Hugs,

JoAnne

[ryansgirl 1]

hugs and kiss hun my insurnace would only cover the rny which is what i didn't want. look at this appeal as another battle in the war. one i know you will win one way or there is lots of great advice above from the ladies on here.

nikki

[Malaika 50]

JoAnne - I think it is a very positive sign that your surgeon is so willing to do all he can to help you - I will keep you in my thoughts and prayers and will be anxious to hear what the ins. co. will say.

[Norma 10]

ASMBS: Gastric Banding Less Effective than Other Procedures

By Charles Bankhead, Staff Writer, MedPage Today

Published: July 02, 2009

Reviewed by Zalman S. Agus, MD; Emeritus Professor

University of Pennsylvania School of Medicine and

Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Earn CME/CE credit

for reading medical news

DALLAS, July 2 -- Patients who underwent laparoscopic adjustable gastric banding achieved less weight loss and less improvement in comorbid conditions than those who had gastric bypass or sleeve gastrectomy. Action Points

• <LI class=APP>Explain to patients that laparoscopic adjustable gastric banding led to less weight loss compared with two other types of obesity surgery.
  
  
• Note that these studies were published as abstracts and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
  

Slightly more than half of gastric banding patients lost more than 50% of excess weight after five years compared with more than 90% of patients who underwent laparoscopic Roux-en-Y gastric bypass, Diego Awruch, MD, reported at the American Society of Metabolic and Bariatric Surgery.

Surgical failure, defined as less than 50% excess weight loss, was almost six times more common with gastric banding.

"Laparoscopic adjustable gastric banding was associated with fewer complications, but the percent weight loss at one and five years was inferior to laparoscopic Roux-en-Y gastric bypass," said Dr. Awruch, of Pontificia Universidad Catolica in Santiago, Chile.

"Surgical failure occurred in more than 40% of patients who underwent gastric banding, and 16% of the patients required surgical revision of the initial procedure," he said.

Similar disparities in weight loss occurred in the comparison of gastric banding and sleeve gastrectomy.

Across the entire range of body mass index (BMI), laparoscopic sleeve gastrectomy led to greater weight loss, said David Schumacher, MD, of Wright State University in Kettering, Ohio.

Dr. Awruch reported outcomes for 91 patients treated with laparoscopic Roux-en-Y surgery and 62 who underwent gastric banding from 2001 to 2003.

Five-year follow-up was available for 73.6% of the gastric bypass patients and 91.5% of the gastric banding patients.

Comparison of baseline characteristics showed that bypass patients weighed significantly more (106.4 versus 97.6 kg, P<0.001) and had a significantly higher BMI (39 versus 35, P<0.001).

Gastric bypass was associated with a higher rate of early complications (14.2% versus 1.6%, P=0.009). In addition, nine bypass patients required reoperation or endoscopic dilatation compared with one patient in the banding group.

Late complications occurred in 37.3% of bypass patients compared with 27.4% of gastric banding patients, but the difference did not reach statistical significance. A higher proportion of gastric banding patients required reintervention (23 of 62 versus 20 of 91).

Percent weight loss at five years averaged 92.9% with gastric bypass compared with 59.1% with gastric banding (P<0.001).

Dyslipidemia, insulin resistance, hypertension, and type 2 diabetes improved or resolved in 80% to 100% of bypass patients compared with 20% to 40% of the gastric banding group.

At five years, 94% of bypass patients and 54.4% of gastric banding patients had maintained >50% excess weight loss.

Dr. Schumacher reported outcome data for 104 patients who underwent laparoscopic sleeve gastrectomy and 227 who had gastric banding from January 2006 through August 2008. Follow-up data were 99% as of January 2009.

Among patients followed for at least 18 months (about half of the total), weight loss averaged 133.82 lb in the sleeve group versus 58.93 lb in the banding group.

For the same time interval, excess weight loss averaged 55.54% with sleeve gastrectomy versus 38.65% with banding.

Stratification of patients by baseline BMI showed that sleeve patients had a greater excess weight loss in patients with BMI more than 50 (50% versus 33%), 40 to 49 (68% versus 40%), and less than 40 (90% versus 43%).

Readmission rates were 6% of sleeve gastrectomy patients and 1.3% with gastric banding. One patient (0.96%) in the sleeve group required reoperation compared with 19 (8.4%) gastric banding patients.

"Laparoscopic sleeve gastrectomy appears to allow greater weight loss in all BMI classifications over time with fewer reoperations," said Dr. Schumacher. "The most efficient weight loss occurred in the lowest BMI classification.

"Laparoscopic sleeve gastrectomy can be used effectively as a primary operation in any weight classification, achieving a greater than 50% excess weight loss in all BMI subsets." Dr. Awruch and co-investigators reported no disclosures. Dr. Schumacher disclosed a relationship with Ethicon.

Primary source: American Society of Metabolic and Bariatric Surgery

Source reference:

Awruch D, et al "Laparoscopic roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding 5 years follow-up" Surg Obes Relat Dis 2009; 5(3S): Abstract PL-122.

Additional source: American Society of Metabolic and Bariatric Surgery

Source reference:

Schumacher DL, et al "Comparison of gastric sleeve and adjustable gastric band over an extended time frame" Surg Obes Relat Dis 2009; 5(3S): Abstract PL-215.

[mountain_lover 3]

JSM---------- Note: this was included in your insurance policy

*Biliopancreatic bypass with duodenal switch

*Sleeve gastrectomy, performed either as a stand-alone restrictive procedure, or as a first stage procedure of a planned biliopancreatic bypass with duodenal switch for patients with a BMI exceeding 50.

Hello jsm,

I would like to point out something that maybe someone is overlooking or is misunderstanding at BlueCross/BlueShield. I may be wrong, but it is something for them to consider. If you notice above the Biliopancreatic Bypass with Duodenal Switch is approved, and it says nothing about any requirements on the BMI. But notice that when the Sleeve Gastrectomy is performed as a "FIRST STAGE PROCEDURE" of a Biliopancreatic Bypass with Dueodenal Switch, it is only approved for "PATIENTS WITH A BMI EXCEEDING 50.

However, the Sleeve Gastrectomy is approved when performed as a "STAND-ALONE RESTRICTIVE PROCEDURE", it does not say any specific BMI . It stipulates that it is EITHER, Or.

---------------------------------

" performed EITHER as a stand-alone restrictive procedure"

"OR as a first stage procedure of a biliopancreatic bypass with duedenal switch for patients with BMI exceeding 50"

--------------------------------

As I stated in my post earlier that I learned that the Duodenal Switch was being performed on patients, but if the patient had a very high BMI and health problems which made it more risky to have the Duodenal Switch, then doctors would perform the Sleeve (Which is the First part of the duodenal surgery and only restrictive), hoping that the patient would lose weight down to a SAFER, LOWER BMI, then the other part of the Duodenal surgery which is Malabsorptive could be performed without all the risks that were present before the Sleeve, so that the patient could lose more weight to reach their goal. ------------>>>>> What many doctors were discovering was that many patients continued to lose the weight and was reaching their goals with only the Sleeve, and the second part of the surgery did not need to be performed. So then many doctors started performing The SLEEVE as a STAND-ALONE RESTRICTIVE PROCEDURE. Now the sleeve is becoming a more sought after surgery by doctors and patients, because it is a less expensive, less evasive, and less risky surgery. Also the doctors know that there are less complications and healing time is faster with the Sleeve vs. the other procedures.--------------->>>>>>>> Medicaid and Medicare are now approving some Sleeve procedures.

As I stated in my other post, WHY PAY FOR MORE IF IT IS NOT NEEDED. When the insurance company pays for the duodenal, the sleeve is the first part of that surgery. People with LOWER BMI and no severe health issues other than obesity, are having success with only the sleeve; so why have people put at more risk just so that they have a covered procedure according to what the insurance company understands the terms to be. Could the insurance company be misunderstanding or misinterpreting the policy coverage, because they might not have all the facts or they might not be reading the sentence above in their policy as it might be intended? If you have any thoughts on this or any more questions, it would be very interesting to hear from anyone. Thank you for taking the time to read this. Also you may get more information on this from doctors who are performing the Sleeve and are able to get it covered by different insurance policies.

[mountain_lover 3]

Thanks Chancie, Susan, Sandy and to all that have replied or just feel my frustration. This is why I love this forum. Everyone is so caring and supportive. I feel like everyone is part of my family.

Your good thoughts and energy keep me going.

Hugs,

JoAnne

Hello jsm,

Please let us know if anything changes. I hope and pray for everything to work out for you.

[jsm 1]

Thanks Mountain_Lover! I am on pins and needles! I'm so nervous not knowing what the outcome of the appeal will be. I thought I would have an answer by last Friday from my surgeon's office on his peer to peer appeal. Apparently that has not happened yet. I left a message late Friday and just a little while ago. I probably have gone from a PITA (pain in the arss) to a full blown Hemmorrhoid calling his office so often.

I'm also afraid to bug my insurance company, since I know my surgeon will be doing the peer to peer appeal.

I'm about 2 weeks away from my scheduled surgery date, and should be starting my liquid diet on Wednesday.

Again, thanks for your thoughts, prayers and good energy. I will post as soon as I hear anything.

Hugs,

JoAnne

[mountain_lover 3]

Thanks Mountain_Lover! I am on pins and needles! I'm so nervous not knowing what the outcome of the appeal will be. I thought I would have an answer by last Friday from my surgeon's office on his peer to peer appeal. Apparently that has not happened yet. I left a message late Friday and just a little while ago. I probably have gone from a PITA (pain in the arss) to a full blown Hemmorrhoid calling his office so often.

I'm also afraid to bug my insurance company, since I know my surgeon will be doing the peer to peer appeal.

I'm about 2 weeks away from my scheduled surgery date, and should be starting my liquid diet on Wednesday.

Again, thanks for your thoughts, prayers and good energy. I will post as soon as I hear anything.

Hugs,

JoAnne

Hello JoAnne,

I posted the following item earlier, I don't know if you noticed. If not, please read it very carefully. It may be difficult to understand. I was thinking that maybe if you were to show this following message to your surgeon, he might find it very interesting. I am sure due to the fact that he is a surgeon, that he would understand what the message is all about and he could possibly use some of it to help in your appeal. It may not help, but it might be worth trying. I am understanding from my surgeon Dr. Husted here in Somerset KY, that the vertical sleeve procedure is now being coverered by Medicaid for some patients. Just a few months ago when I went to my consult with him, they were not being approved by Medicaid, but he told me he was going to be speaking with Medicaid about getting them approved here in KY. He must have been successful or something has changed, because recently a few of his patients have been approved for the sleeve by Medicaid. I sure hope all this is true, because it has so much to do with me being able to have the sleeve done in my situation. Maybe if it is true, then other States will make it possible for Medicaid patients to get approved for a safer surgery. Also people could stay in there own area and not have to go elsewhere if they find a good surgeon who accepts Medicaid for their sleeve procedure. PLEASE READ THE FOLLOWING AND POSSIBLY LET YOUR SURGEON READ IT IF YOU THINK IT MIGHT HELP IN YOUR APPEAL!!!

JSM---------- Note: this was included in your insurance policy

*Biliopancreatic bypass with duodenal switch

*Sleeve gastrectomy, performed either as a stand-alone restrictive procedure, or as a first stage procedure of a planned biliopancreatic bypass with duodenal switch for patients with a BMI exceeding 50.

Hello jsm,

I would like to point out something that maybe someone is overlooking or is misunderstanding at BlueCross/BlueShield. I may be wrong, but it is something for them to consider. If you notice above the Biliopancreatic Bypass with Duodenal Switch is approved, and it says nothing about any requirements on the BMI. But notice that when the Sleeve Gastrectomy is performed as a "FIRST STAGE PROCEDURE" of a Biliopancreatic Bypass with Dueodenal Switch, it is only approved for "PATIENTS WITH A BMI EXCEEDING 50.

However, the Sleeve Gastrectomy is approved when performed as a "STAND-ALONE RESTRICTIVE PROCEDURE", it does not say any specific BMI . It stipulates that it is EITHER, Or.

---------------------------------

" performed EITHER as a stand-alone restrictive procedure"

"OR as a first stage procedure of a biliopancreatic bypass with duedenal switch for patients with BMI exceeding 50"

--------------------------------

As I stated in my post earlier that I learned that the Duodenal Switch was being performed on patients, but if the patient had a very high BMI and health problems which made it more risky to have the Duodenal Switch, then doctors would perform the Sleeve (Which is the First part of the duodenal surgery and only restrictive), hoping that the patient would lose weight down to a SAFER, LOWER BMI, then the other part of the Duodenal surgery which is Malabsorptive could be performed without all the risks that were present before the Sleeve, so that the patient could lose more weight to reach their goal. ------------>>>>> What many doctors were discovering was that many patients continued to lose the weight and was reaching their goals with only the Sleeve, and the second part of the surgery did not need to be performed. So then many doctors started performing The SLEEVE as a STAND-ALONE RESTRICTIVE PROCEDURE. Now the sleeve is becoming a more sought after surgery by doctors and patients, because it is a less expensive, less evasive, and less risky surgery. Also the doctors know that there are less complications and healing time is faster with the Sleeve vs. the other procedures.--------------->>>>>>>> Medicaid and Medicare are now approving some Sleeve procedures.

As I stated in my other post, WHY PAY FOR MORE IF IT IS NOT NEEDED. When the insurance company pays for the duodenal, the sleeve is the first part of that surgery. People with LOWER BMI and no severe health issues other than obesity, are having success with only the sleeve; so why have people put at more risk just so that they have a covered procedure according to what the insurance company understands the terms to be. Could the insurance company be misunderstanding or misinterpreting the policy coverage, because they might not have all the facts or they might not be reading the sentence above in their policy as it might be intended? If you have any thoughts on this or any more questions, it would be very interesting to hear from anyone. Thank you for taking the time to read this. Also you may get more information on this from doctors who are performing the Sleeve and are able to get it covered by different insurance policies.

Have a good day from mountain_lover!!

[jsm 1]

Hi Mountain_Lover,

I totally agree that our medical policy makes no sense and that I also interpret the policy as approved for standalone with no BMI restrictions. However, according to the Director of Pre-Cert, VSG is only approved for those with BMI > 50.

I have tried to get a status on my appeal, but was told it was in review and that a decision would be made by 11/1. I have no idea if my surgeon has done a peer to peer appeal yet, since the assistant that tracks that is out of his office until tomorrow. I have also called several Dr's in Mexico. Southwest is having an airfare sale till Thursday. I have found air for around $100 each way. Amazing for coast to coast!

At any rate, I started my 2 week Pre-Op diet today (as far as I know my surgery date is still 11/10, just in case.

So, I'm still in a wait and see mode, trying to stay positive that this will all work out. :thumbup1: I really hope I don't cave in to RNY since self-pay would not be easy for me at this time.

Hugs,

JoAnne