How can I get a revision approval from Blue Shield-convert from a RYN toa DS?

sjalex
on 11/27/10 2:23 pm - CA

Has anyone had to get an approval from Blue Shield of California for a revision? I am currently researching if I can get an approval to have a revision from a RYN to a DS. A doctors office here in California did some research and the following is the information they sent to me:

I assume you’re interested in having your RNY converted to a Duodenal Switch; Blue Shield told me that your policy would cover surgery with our doctor if they would authorize the surgery; however, they won’t authorize a Duodenal Switch unless the patient’s body mass index is at least 50 (yours appears to be in the 40s). If you would like, we could submit an authorization request to them for the Duodenal Switch and you could send an appeal to ask that they cover it for you, but it would be difficult to convince them to approve it. Other patients have recently tried to appeal the BMI-of-50 issue, but they were unsuccessful even with our help. If you’re interested in the Vertical Gastrectomy procedure, the news appears to be better, as your BMI only has to be 40 for them to cover it. Feel free to let me know if you’re interested in that procedure; if so, we may be able to get you authorized for it. Blue Shield doesn’t appear to have any coverage criteria specifically for conversion of one procedure to another; the closest I can find in their guidelines is as follows (this is cut and pasted from their bariatric surgery guidelines as published on their website): -Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch (documented by upper gastrointestinal examination or endoscopy) is considered medically necessary when all of the following are met: • The initial procedure was successful in inducing weight loss prior to pouch dilation • The patient has been compliant with a prescribed nutrition and exercise program • The patient still meets BMI criteria for bariatric surgery

Any suggestions?????

Stacey

danas
on 11/28/10 6:27 am - CA

DS on 01/29/10

Which Dr's office said this? I would suggest going to go see either Dr. Keshishian (Glendale) or Dr. Rabkin (San Francisco). They are both fantastic revision surgeons & would be the most able to help you with your insurance. You can find more info about these Dr's on dsfacts.com. HTH!

Won against big bad (SoCal) Kaiser for a Duodenal Switch Haven't heard of DS? Kaiser wants it that way. Come on over & read the truth.
Hit goal (Normal BMI) on 2-10-11! I LOVE my DS!!
My approval process timeline:
02/12/09 - Dr. refused to refer me for WLS
03/03/09 - Vented/whined about it on another board, planned to just wait until next year & switch plans
Let's see what happens!

**updates in blog**

sjalex
on 11/28/10 1:59 pm - CA

RNY on 09/26/01

Thanks. To answer your question on which doctor's office provided this information, it's Dr Rabkins. Thanks again for your help.

Stacey

How can I get a revision approval from Blue Shield-convert from a RYN toa DS?

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How can I get a revision approval from Blue Shield-convert from a RYN toa DS?