Revision in one operation or two??

[Ellisa 6]

Lynn, I know you must be soooo excited and relieved!

Insurance will not cover the sleeve portion of my surgery, so awaiting the bills. Ugh. But it'll be worth it. I really think my reduced stomach mass will contribute to the hiatal herna repair holding.

[Jill 0]

Lynn, I know you must be soooo excited and relieved!

Insurance will not cover the sleeve portion of my surgery, so awaiting the bills. Ugh. But it'll be worth it. I really think my reduced stomach mass will contribute to the hiatal herna repair holding.

Why won't they cover the Sleeve? I appealed 11 denials until I was appropved.

Jill

[Ellisa 6]

My insurance considers it to be experimental. It will cover the band and GBS, but not sleeve. Since my BMI no longer meets their requirements it won't cover any WLS for me now. But it did approve the hiatal hernia repair and band removal.

[mila1013 0]

Why won't they cover the Sleeve? I appealed 11 denials until I was appropved.

Jill

appealed 11 denials, good for you!!!!

[Jill 0]

My insurance considers it to be experimental. It will cover the band and GBS, but not sleeve. Since my BMI no longer meets their requirements it won't cover any WLS for me now. But it did approve the hiatal hernia repair and band removal.

They verbally asked me about the gastric bypass and I told they why I did not want that procedure and why I wanted the Sleeve. I was adamant until they said yes.

[mila1013 0]

My insurance considers it to be experimental. It will cover the band and GBS, but not sleeve. Since my BMI no longer meets their requirements it won't cover any WLS for me now. But it did approve the hiatal hernia repair and band removal.

When you have an insurance co that cover both RNY and GB, the investigational tag can be appealed and most often overturned, you have nothing to lose but to try to appeal the decision. The BMI no longer meeting requirments is flimsly at best, you had established mobid obesity before the band, I would still appeal. It is obsurd for an insurance co to state in writing "that you have to gain weight to qualitfy for revision surgery" on appeal that would not be upheald, it is like saying that you have had surgery for breast cancer it didnt work and you need another surgery but they would only cover it if the cancer was back that has been in remission by chemo and radiation-yep that would never happen, morbid obesity is a disease and deserves to be treated like one-but you have to do your homework and appeal using your specific contract language-you have nothing to lose, I feel like you have blue cross, they are great for that-good luck with anything you choose, appeal insurance is not for people who can not stand BS as they shovel it out pretty heavily

Edited July 16, 2010 by mila1013

[Jill 0]

appealed 11 denials, good for you!!!!

Thanks, it was frustrating to say the least. They put me through all kinds of nonsense and kept requesting records and information over and over and medically supervised diets and such. At the end I got a person on the phone and she went to the superviser on my behalf and was finally able to get me approved. I had to have all my ducks in a row and submit everything that was required. It wasn't easy and took me eight months.

Jill

[mila1013 0]

yep that is expected of insurance co, especially blue cross, they hope you don't know what is in your subscriber agreement and are afraid and you will give up---

Thanks, it was frustrating to say the least. They put me through all kinds of nonsense and kept requesting records and information over and over and medically supervised diets and such. At the end I got a person on the phone and she went to the superviser on my behalf and was finally able to get me approved. I had to have all my ducks in a row and submit everything that was required. It wasn't easy and took me eight months.

Jill

[Ellisa 6]

Food for thought for sure. I will try the appeal process, do you know if "after the fact" surgeries are even eligible for appeal with insurance companies? Mine does not approve WLS for BMIs below 35 and then with two co-morbs, and I have no co-morbs. GERD isn't considered a co morb on my policy, has to be high blood pressure, diabetes or sleep apnea. etc. none of which I've ever had. I've heard some insurances count things like GERD, incontinence, arthritis, Fibromyalgia, etc. Mine does not. My BMI had to be 40+.

Edited July 16, 2010 by Ellisa
Clarification

[Jill 0]

Ellisa, I agree with Mila. I have Blue Cross/Blue Shield of Illinois and I live in Florida. They kept requesting document after document and wanted medically supervised diets and other doctor visits, which I complied and then sent to them. At the end, I got the person on the phone who wrote the denial letters who told me that she was on my side and was the middle man. Of course I did not believe her, but it turned out to be true. She asked me about gastric bypass and I told her why I did not want that procedure and why the Sleeve was best for my situation. She listened and went to the medical director who denied me and said that I needed other information, which I actually had already submitted, so I refaxed that information directly to this woman who went back to the medical director and presented my information and my story and I was approved the next day.

Jill

[Jill 0]

food for thought for sure. I will try the appeal process, do you know if "after the fact" surgeries are even eligible for appeal with insurance companies? Mine does not approve WLS for BMIs below 35 and then with two co-morbs, and I have no co-morbs. GERD isn't considered a co morb on my policy, has to be high blood pressure, diabetes or sleep apnea. etc. none of which I've ever had. I've heard some insurances count things like GERD, incontinence, arthritis, Fibromyalgia, etc. Mine does not. My BMI had to be 40+.

How do you know this specifically? Is the language in the policy "we will not approve for BMIs under 35, nor for GERD no matter what the reason." Or were you denied because you didn't meet certain criteria? You really need to read the denial letter and read between the lines. How many times have you appealed?

Jill

[Ellisa 6]

I have BC/BS Ohio. But I'm understanding that my employer is really self insured. BC/BS just administer it. With my band, I went through the pre surgical approval process. They said they didn?t have the paperwork numerous times but in the end, and so many copies of it that the woman who personally called to say it was approved couldn?t understand why my doc?s office had bombarded them with so many copies. LOL But all in all it was approved without any denial and really within maybe 6 weeks. We didn?t even attempt to have the sleeve approved, well frankly, I was planning/hoping to KEEP my band. The sleeve was discussed and agreed upon only if removing my band was necessary for the healing of the hernia. I was having so much discomfort I couldn?t wait the weeks it would take to get the denial, then how many more for appeals? I?m definitely going to look into appealing though and thanks for all the information.

[Jill 0]

I have BC/BS Ohio. But I'm understanding that my employer is really self insured. BC/BS just administer it. With my band, I went through the pre surgical approval process. They said they didn?t have the paperwork numerous times but in the end, and so many copies of it that the woman who personally called to say it was approved couldn?t understand why my doc?s office had bombarded them with so many copies. LOL But all in all it was approved without any denial and really within maybe 6 weeks. We didn?t even attempt to have the sleeve approved, well frankly, I was planning/hoping to KEEP my band. The sleeve was discussed and agreed upon only if removing my band was necessary for the healing of the hernia. I was having so much discomfort I couldn?t wait the weeks it would take to get the denial, then how many more for appeals? I?m definitely going to look into appealing though and thanks for all the information.

Ah, that is a horse of a different color!

Jill

[Ellisa 6]

How do you know this specifically? Is the language in the policy "we will not approve for BMIs under 35, nor for GERD no matter what the reason." Or were you denied because you didn't meet certain criteria? You really need to read the denial letter and read between the lines. How many times have you appealed?

Jill

Jill it's been nearly 3 years ago since I was going through that, but at the time but it said the the requirements were 40+ BMI or 35+ BMI with two co-morbsand a 5 year history of obesity; I had to have one weight from a doctor's office for each of those years.. I had to get them from my PCP, OBGYN, various urgent care facilities, because I'm not good about going to any one doc every single year... and sometimes I had (stupidly skipped the weight in.).The co morbs weren't an issue for me because I met the higher BMI. But I do remember that the insurance person in my docs office knew which ones our policy considered co-morbs and which they did not.

BTW, I did not have to provide months of medically supervised weight loss. I only had to list diets I'd tried, weight lost/regained and so forth as well as a medical history proving 5 years of obesity. Though my BMI wasn't even above 35 the entire time 5 years, I explained that I was constantly trying to lose weight. They approved it without ever denying it.

[Jill 0]

Jill it's been nearly 3 years ago since I was going through that, but at the time but it said the the requirements were 40+ BMI or 35+ BMI with two co-morbsand a 5 year history of obesity; I had to have one weight from a doctor's office for each of those years.. I had to get them from my PCP, OBGYN, various urgent care facilities, because I'm not good about going to any one doc every single year... and sometimes I had (stupidly skipped the weight in.).The co morbs weren't an issue for me because I met the higher BMI. But I do remember that the insurance person in my docs office knew which ones our policy considered co-morbs and which they did not.

BTW, I did not have to provide months of medically supervised weight loss. I only had to list diets I'd tried, weight lost/regained and so forth as well as a medical history proving 5 years of obesity. Though my BMI wasn't even above 35 the entire time 5 years, I explained that I was constantly trying to lose weight. They approved it without ever denying it.

Gotcha. Still horse of a different color. I wouldn't imagine they would approve you after the fact and in light of the above circumstances.

Jill