My insurance denies sleeve...approves RNY, I want sleeve...help

[smokenhaze 9]

The journey has been smooth until now. I get my insurance through my employer, professional benefit administrators (PBA). My medical insurance with them in through Cigna. Now I got pre approval and went through six months diet requirement. Doctor submitted insurance and today I get the call that sleeve was denied that I only and covered for gastric bypass. Now I have been dealing with the which one I want and decided for my lifestyles and my needs that sleeve will do much better. I don't want to give up even though insurance is saying there is no loop hole. If I appeal that could be another 30-90 days!!.

Cigna approves sleeve but PBA (my actual insurance) does not cover sleeve. I need to know what else can I do other than resubmit for bypass. Do I need a doctor approval for sleeve. Is there a loophole any where. I don't want to wait to do an appeal but if I have to I will. But I want the appeal to work. no more waiting. I need the sleeve and I hope there is a way. Help.

[Bufflehead 6,358]

Usually if they won't approve sleeve, then they won't approve sleeve . . . no easy loophole. But if your surgeon and/or PCP can find a medical reason that bypass would not work for you but a sleeve would, you might be able to appeal on that ground. For example: you have a condition such as arthritis that means you will need to take NSAIADs after surgery. You have irritable bowel syndrome, Crohn's Disease, or another intestinal disease that would make surgery on the intestines risky or impossible. Your surgeon will probably be the best person to consult for other possible reasons.

If your insurance still won't cover it, I would think your options are either self-pay (in the US or Mexico/abroad) or see if you can find other insurance that does cover the sleeve - perhaps through a spouse or partner, a professional association, the Affordable Care Act exchange in your state, etc. Good luck!

[Jersrose43 837]

Sounds like a benefit exclusion and if that's the case no appeal for medical necessity will be useful at all.

Call PBA as soon as you can and verify if it's a benefit exclusion or something else as soon as possible. This way you won't waste your time on unnecessary appeals

[smokenhaze 9]

Jersrose43 i called pba and they said its a benefit exclusion, and they weren't very helpful on answering my questions. What does benefit exclusion mean? They kept on mentioning that the billing code for the surgery was 43775. I saw on on ObesityCoverage.com this

We’re happy to announce that the new CPT (billing code) for gastric sleeve procedures is 43846 and we hope that your insurance company will cover gastric sleeve surgery soon.

Can I resubmit for that different code and possibly get a different answer?

[jtickle 295]

A benefit exclusion means the insurance company will not pay for it. Appealing won't even do any good because the sleeve is an excluded benefit.

Edited April 15, 2014 by jtickle

[Jersrose43 837]

Correct benefit exclusion is just that. No matter what code they use that procedure no matter the need will not be paid for

Get on a spouse plan if at all possible

If not purchase individual jnsurance that has the benefit - check and trike check

Last resort you'd have to pay cash

[smokenhaze 9]

Jersrose43 no husband, no money to pay cash. I can't seem to find an insurance plan. I just dont know. Im so disappointed that i might have to do bypass and ill die.

[wendyt 108]

Why would you die with a bypass? Didn't you say you were debating which one to get, they bypass or sleeve? Or am I reading it wrong?

Talk to your doc more about the procedure that IS covered; you might find that it will suit your needs just fine.

[Jersrose43 837]

Jersrose43 no husband, no money to pay cash. I can't seem to find an insurance plan. I just dont know. Im so disappointed that i might have to do bypass and ill die.

I would recommend Looking for healthcare through a private plan then and purchasing it of they pay for it.

[Bufflehead 6,358]

A bypass may not be your first choice, but tons of people get bypass and do fantastic. Don't rule it out. There are bypass people in my support group and they don't seem to have any more complications or problems than sleevers do. My niece had bypass and she lost 175+ pounds and has kept it off for over four years. It's an individual thing -- but I know I would not have hesitated to have a bypass if a sleeve had not been available to me. Good luck in your decision.