Gastric Sleeve Surgery Denied!

[Shellyac 22]

Generally it is BMI of 35+ with 2 comorbidities or BMI of 40 or higher with no comorbidities that will easily get you approved for the band of the bypass. The sleeve is tricky. Like I said my insurance says your BMI must be 50 or higher. I think that this is probably due to the fact that the sleeve was initially used as the first stage of the Duodenal Switch which was a surgery that was reserved for the super obese. This requirement may soon change since the sleeve is now becoming accepted a primary procedure for lower BMI patients.

[hadouni 301]

I have BCBS too and my case is going out for pre-approval. I'm 40 or 41 BMI and I really hope they approve it. If I have to have GBS I will, but I'd so prefer to have a sleeve. My surgeon's office has never said they thought approval would be an issue on any of the procedures. Fingers crossed!

[SleeveDreamer 383]

I have Anthem Blue Cross and they have a BMI of 35 and mine was 32 so they would not even look at it. My issue is that 60% of my weight is fat. My doctor says they get a number down and they won't budge from it. They don't care about the individual and other issues they may have. He said they get incentive bonuses for reaching a particular amount for denials. So I am paying for this myself (luckily I have good credit). I heard that after January 1st alot of companies were no longer going to cover alot of bariatric surgery because they feel as though it has become a fad. What is our world coming to?

[Shellyac 22]

I just posted this in the insurance forum. Hopefully this info can help

I believe that one of the main reasons that people are being denied the sleeve is that they don't meet the 50 or higher BMI requirement. I was looking at BCBS Mid Atlantic's requirement information and found the following information.

The company's policy is based on a position paper from the American Society for Metabolic & Bariatric Surgery

Sleeve Gastrectomy, Update 2008, January:

Sleeve gastrectomy has been proposed both as a stand alone gastric restrictive procedure, and as a first stage operation for the extremely morbidly obese patients, e.g. those with body mass index (BMI) exceeding 50, or for those with serious comorbid conditions that would increase risk for morbidity and mortality with the initial use of a malabsorptive procedure such as a gastric bypass with Roux-en-Y anastamosis or duodenal switch. Bariatric specialists believe that with the initial weight loss and improvement of comorbid conditions following the sleeve gastrectomy, the malapsorptive procedure can be performed at a later time if necessary with greater safety. In June of 2007, the American Society for Metabolic and Bariatric Surgery (ASMBS) published a position statement on sleeve gastrectomy as a bariatric procedure. The paper states that sleeve gastrectomy may be an option for carefully selected patients, particularly those who are at high risk or super-obese, and that the concept of staging bariatric surgery may have value as a risk reduction strategy in high-risk patients. The paper also suggests that surgeons performing sleeve gastrectomy prospectively collect and report outcomes data in the scientific literature. Finally, the paper suggests that surgeons performing sleeve gastrectomy inform their patients regarding the lack of published evidence for sustained weight loss beyond 3 years, and provide information regarding alternative procedures with published long-term (>5 years) data confirming sustained weight loss and comorbidity resolution.

The ASMBS has updated their position as of October of 2011

I have posted the summary but the full report can be found here

Substantial comparative and long-term data are now published in the peer-reviewed literature demonstrating durable weight loss, improved medical comorbidities, long-term patient satisfaction, and improved quality of life after SG. The ASMBS therefore recognizes SG as an acceptable option as a primary bariatric procedure and as a first stage procedure in high risk patients as part of a planned staged approach. Based on the current published literature, SG has a risk/benefit profile that lies between the laparoscopic adjustable gastric band and the laparoscopic Roux-en-Y gastric bypass. As with any bariatric procedure, long-term weight regain can occur and, in the case of SG, this could be managed effectively with re-intervention. Informed consent for SG used as a primary procedure should be consistent with consent provided for other bariatric procedures and should include the risk of long-term weight gain. Surgeons performing SG are encouraged to continue to prospectively collect and report outcome data in the peer-reviewed scientific literature.

Since this position paper is so new it is very likely that your insurance company has not used it to update their policy. I would encourage those of you who have been denied to forward this report to your insurance company as part of your appeal.