Bcbs

[fatgal78 0]

Does anyone know how often they review and update these medical policies?

My surgeon recommended either RNY or sleeve for me and after tons of research, I decided that the sleeve was the best fit for me. THEN I find out my insurace considers it expieremental and it isn't covered. RNY scares the heck out of me.

The sleeve has been out long enough (I feel) to see that it is better than RNY. I just don't know what to do. I mean I can't afford to pay out of pocket so I can either go ahead with RNY or stop everything and wait until my insurance covers the sleeve, but how long will that be?

Any suggestions? On my medical policy, the last time they looked at the sleeve was 9/2008. It is 2010.

[Tiffykins 673]

First step is to get a denial letter starting the reasons for the denial. So, your surgeon would still have to submit the paperwork for approval and then get a denial response letter from the insurance company. Also, getting a letter of support from your primary doctor, and any other doctors you may see for related co-morbidities. Also, documented attempted and failed weight loss attempts such as diets/exercising, and why you need surgery that will get you to healthy weight, and a surgery that will help you maintain your weightloss. I'm with you on the RNY being scary. I was having no part of that one considering how many RNY patients seek a revision in 5-8 years or so because of regain.

Then you can appeal the decision. Here is a list of sample appeal letters with recent research and published studies discussing that VSG is a successful procedure as a stand-alone surgery.

This is a lot of information, but you have to get the denial letter before you can appeal the decision.

One of the factors to consider with RNY or lapband is that you can not take NSAIDS (alleve or ibuprofen) with either of those surgeries. But, you can take them with the sleeve. So, if you need to take NSAIDS make sure to have that included in your letter.

This is a lot of info, but all the published studies, and ASMBS statement that the sleeve is a successful stand-alone procedure.

http://www.obesityhelp.com/morbidobesity/information/wlsjourney/insurance+trouble.php

http://verticalsleevetalk.com/insurance-financing/1496-my-appeal-draft-w-references.html#post14133

http://vsgappeal.blogspot.com/2009/06/appeal-letter.html

http://verticalsleevetalk.com/pre-operation-vertical-sleeve-surgery-vsg-questions-answers/1751-unapproved-sleeve-ready-cry-2.html#post17480

http://thediaryofafatwoman.blogspot.com/2008/11/deny-deny-deny.html

Edited January 28, 2010 by Tiffykins