Please read this if you need to appeal (bcbs and other companies)

mountain_lover · October 28, 2009

I previously posted this following message on the Pre-Op forum on here, I decided to copy it and paste it on this new thread about Insurance & financing. If you find it interesting, you may want to show it to your surgeon. I tried to put it down in the terms that I understand them to be, but maybe whoever is appealing your case can put this in addition to all their other information, to try to get you approved for the sleeve.

PLEASE READ THIS:

Re: Unapproved for Sleeve - Ready to CRY

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Quote:

Originally Posted by jsm

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.

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" 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"

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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!!

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mountain_lover