UPMC Canceled approval?

[gdetty 3]

Does anyone have information that can help me? I called UPMC Health Plan (University of Pittsburgh) in January and asked if I was covered for the VSG. The answer was yes. I started my 6-month Pre-Surgical supervised diet, weight program; lost weight, lowered my blood glucose, had my psychological evaluation and even met the surgeon. I thought I was ready to go. At this time, I was told to call "again" because on February 5th 2010 UPMC stopped covering the VSG. This was confirmed by the Surgeon and his PA. I appealed. But of course my appeal was denied and I have no proof. Has anyone had a similar experience with UPMC and/or has anyone had the VSG procedure under the UPMC Plan? I am appealing to change my plan from UPMC to Blue Cross of Illinois who is approving the VSG.

[thisislou 13]

Does anyone have information that can help me? I called UPMC Health Plan (University of Pittsburgh) in January and asked if I was covered for the VSG. The answer was yes. I started my 6-month Pre-Surgical supervised diet, weight program; lost weight, lowered my blood glucose, had my psychological evaluation and even met the surgeon. I thought I was ready to go. At this time, I was told to call "again" because on February 5th 2010 UPMC stopped covering the VSG. This was confirmed by the Surgeon and his PA. I appealed. But of course my appeal was denied and I have no proof. Has anyone had a similar experience with UPMC and/or has anyone had the VSG procedure under the UPMC Plan? I am appealing to change my plan from UPMC to Blue Cross of Illinois who is approving the VSG.

Hey

I was just denied last week for BCBS of Illinois because their procedure has not changed and VSG is still "experimental and investigational". Do you know something that I do not? I am in the process of writing up my appeal in an attempt to reverse their decision. Once they saw that I was asking for the VSG code 43775 - it was an instance "no". Has anyone been successful winning an appeal with BCBS of Illinois?

Lou

[gdetty 3]

I can answer this way. I was sent, (from UPMC) instructional videos that demonstrated the procedures for Gastric Bypass and the LapBand, back in early 2009 from a counselor under one of their programs. After I viewed these procedures I adamantly declined to consider either of these procedures. My reasoning was side effects and these side effects would not be tolerable for what I deemed a quality of life for me and what I do. So although, when I called for pre-approval the first time (December 2009), I may not have known what questions to ask, however when I called UPMC Insurance the second time (January 2010), I knew to not misrepresent the procedure I was requesting e.g. VSG. I specifically asked for that procedure coverage (or hence I would not have started my 6-month supervised weight, diet, evaluation time period pre-surgery, because I had already declined the other two procedures).

Having been denied for my appeal, directed at the UPMC insurance company, and since I have an option, when I called Blue Cross of Illinois, I made sure I asked (three-times) if I would be covered for Bariatric Surgery AND specifically the Vertical Sleeve procedure, Each time the party on the other end replied "yes."

Maybe it comes down to different coverages under different Plans due to different payments, (or Group numbers). I can draw a parallel this way, my boss had his VSG surgery in December 2009 and it was approved and covered. I may need to call back and tape the conversation, but my intention now is to verify, verify, verify some way, since I will never consider the other options.

[pnw218 14]

Not totally to the point, but I remember someone else's post and I thought it was very creative and could be the answer for many ....

seems there are insurance companies who will approve the sleeve as part one of a two part bypass surgery.

and then the patient declines or simply forgets : ), to go back for part two of the surgery.

I think the surgeon agreed with the tactic as a way to get the insurance to cover it.

I am always about being creative to get thru red tape to get things done!

[brittu 42]

If it helps, I've posted all my appeal letters on a blog site. I was able to convince Regence that VSG is not investigational. Now I'm just fighting to get them agree I don't have to regain all my weight before they pay for the revision (grrrr).

Britt

My Revision Appeal: From Lap Band to VSG

[gdetty 3]

I'm back at it. I meet next Thursday July 29th for my step 2 appeal for the VSG at UPMC. They asked if I wanted to be there in person ... you bet I do.

I have my case prepared and also a trump card that if I'm denied by UPMC Health Insurance, next year I'll switch to the PPO that is offered which is approving the VSG. I have one of those Cadillac health plans as they are called. Yeah right Cadillac my a&%.

[Kelkie 0]

Good luck. Give 'em HELL!!

[Dansha 16]

Best wishes on your appeal process. I'm pulling for you.

Deb