your opinons please

[KRYSTL166 0]

I'm a nurse, and I have a patient that needs surgery. No information here because of hippa, but I want your opinons. Patients been in and out of hospital for past 2 yrs with same insurance. Its all weight related. Patient called BCBS TX and they told patient they dnt cover it. My doc basically said its life or death for him. I really want to help get him approved but not sure how to proceed. Suggestions anyone?

[Stacy160 201]

It really depends on the reason his insurance doesn't cover it... is bariatric surgery included in his policy but they still consider VSG "experimental"? Or is it specifically excluded from his policy?

If they cover the band and RNY but not VSG, he might stand a chance. People have won on appeal, when they've had medical reasons for NOT getting RNY (intestinal/bowel issues, reliance on NSAIDS for other conditions).

If it's specifically excluded from his policy, that's on his employer and not the insurance company. Many of us, including me, were in the same boat... the insurance itself covers WLS, but our employers cut that out of the policy to save money. If that's the case, then there's really nothing to be done about it and he'll have to find a way to self-pay.

That said, VSG can be had for less than half the cost of a new car (that's how I looked at it), and for a self-payor it's the safest way to go financially, with a super-low risk of complications. I hope your guy can find a way to make it work! :001_smile:

[KRYSTL166 0]

Thank you! I'm going to call him Monday and have him call his employer and see what they can tell me. Hopefully I can help him somehow!