Does insurance (UHC) approve experimental surgeries

[janedoe92 260]

So the surgery I want (SIPS, modified DS) isn't technically covered, but my surgeon is going to speak to the director. Has anyone ever had luck having experimental surgeries covered?

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[RickM 1,753]

The whole experimental/investigational category is a bit of a catch-all for anything the insurance company doesn't want to cover. Some procedures are genuinely investigational in that they are new or novel approaches that aren't well vetted yet (which would include the SIPS/SADI, though that is getting more borderline these days) while others are ones that have been around but never gained traction or acceptance within the US medical community (such as the mini-bypass or the Scopinaro/BPD precursor to the DS, though that one was fairly well accepted in Europe.) Some companies are slower to accept newer procedures than others, even when they have been accepted or vetted by the relevant medical organization such as the ASMBS. 11-12 years ago we fought hard to get coverage from Aetna for my wife's DS with no luck while others got insurance approval for it with no problem. A couple of years later, Medicare started covering the DS, so the experimental/investigational dodge no longer worked for them. OTOH, Aetna started covering the VSG well before Medicare and other insurance companies started covering it. Go figure.

Those I know who have gotten reversals on insurance decisions in this direction did so with appeals (usually several, and often to the state regulatory level) and usually had some compelling reason why their preferred procedure (typically the DS in those days) was more appropriate medically for them than the standard offered procedures. Hopefully, your surgeon can convince them with the peer-to-peer review and you can get on with life.

Good luck!

[Aggiemae 739]

I don't think any insurance companies cover this. Most of them don't even get on board with new approved procedures until they have been around for a while.

[janedoe92 260]

Thanks for yalls information. It was disheartening at first to hear it's not covered, but definitely doesn't stop my journey, just changes it up a bit. Hopefully my surgeon is able to convince them, but if not that's fine too.

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[RickM 1,753]

I have found a couple around these boards that have gotten insurance coverage for the SIPS/SADI, so it seems that somebody out there is covering it. Perhaps the insurance coordinator in your surgeon's office knows which company(s) may be covering it if your company can't be convinced, though that would probably mean delaying things a while until coverage can be transferred, if such is at all possible. We went the self pay route for my wife's DS as the bypass and bands weren't appropriate for her needs,

[janedoe92 260]

I have found a couple around these boards that have gotten insurance coverage for the SIPS/SADI, so it seems that somebody out there is covering it. Perhaps the insurance coordinator in your surgeon's office knows which company(s) may be covering it if your company can't be convinced, though that would probably mean delaying things a while until coverage can be transferred, if such is at all possible. We went the self pay route for my wife's DS as the bypass and bands weren't appropriate for her needs,

Well the good thing is my surgeon has been doing this awhile, and they seemed like they knew a lot about my insurance, and he's supposed to talk to the director that approves surgeries to get it overturned, so hopefully that will happen pretty soon because they already scheduled me, and I'd hate to have to reschedule.

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