Newbie insurance ?s, please help

My company's insurance enrollment is coming up and WLS will no longer be excluded as of 2012. The catch is that all surgey must be performed by one preselected surgeon's office in the state, of course this surgeon does not perform the DS. My BMI is 60+, so there is really no point in having any other surgery type. The 2 companies I can choose from are, UMR ppo or Health PIan of Nevada HMO. When I called UMR directly to find out if the DS is even considered a noninvestigational surgery by them in general, they said all WLS must be performed by the specific surgeon's officce or it's not covered.

Is it realistic to hope I can get my insurance to cover an out of state provider?  I ask because I am also consulting with Dr. Yashkov, and dont want to waste my time jumping through the insurance company's hoops; 6 month diet, twelve 2 hour nutrtition classes, months/year of appeals, ect, if there is very little hope of being approved for a DS.  My copay would be $5000-11,000 if approved through insurance, and Dr Yashkov when factoring in airfare, hotel, and miscellaneous expenses is less than $9500. Has anyone had a positive outcome with this type of insurance situation?

Thanks.
 

Who is Dr. Yashkov and where did you find him?

http://www.dsfacts.com/Duodenal-Switch-Surgeons-from-Asia-Australia-Europe-and-South-America.html
Russia, Moscow,Yury Yashkov, MD, PhD
 his correct email is yu@yashko​v.ru
he charges $7000 or $7700 for SMO

He has quite a few patients from Norway, check out the Norwegian WLS forum:
http://www.vektoperasjon.no/forum/ , i just use google translate, russland is russia in norwegian if you want to do forum searches
also another girl from Norway blogged about her exprience
http://mittgaleliv.blogspot.com/2009_09_01_archive.html

Yes, i'm scared of dying in Russia.

Where are you?

I feel better knowing he is vetted. Sorry that I was too lazy to look it up myself first.

I sencodn airbender's reply - if you can find a DS surgeon who also performs RNY, get him/her to write a letter stating that RNY wold not be successful for you at your state of SMO, based on *facts* particular to your case, like co-morbidities, rate of success with patients at your BMI.  

All insurance coverage is a crapshoot, IMHO, whether it's the DS or prescriptions not on the formulary.

It's definely worth the effort!  

first it is not your concern if the insurance co has a surgoen who doesn't perform a surgery that has been deemed medically necessary for you, that is their problem, and there is the catch.  For example I have a HMO, no one in network performed the DS, I had to fly to find a surgeon, since the DS was deemed medically necessary, the insurance co has to provide a surgeon who can perform the surgery, so I went out of network and and my surgery was considered in network, with co pays ets.  The catch is to follow the rules to get WLS covered, considered medically necessary, then they have to find a provider that performs the DS....wishing you welll.....

I dont really get what is the point of even doing the insurance battle when your copay could be so HIGH???  If he is a vetted surgeon and he charges less with travel- and you would have to travel within the states too and with your copay it would be the same or more expensive .... well it would actually be more expensive once you factor in all the preop things that insurance will require you to also pay for .

Russia is not some third world country.... you would get top notch medical care there too... If his prices are accurate i would go for it b/c your copay seems VERY high.

I obviously think he is an excellent surgeon, or he wouldn't even be on my radar.

I am an only child, and the first grandchild on both sides, in the last two years two close family friends have died due to complications from WLS, both rnys. My family can hardly handle the idea of the Lapband, especially with no co-morbs, even at 450lbs. If I have surgery in the SF bay area or somewhere close, and my mother is able to converse with, aka badger to death, a local surgeon, she may break and become supportive. RUSSIA for a DS?? I would literaly ( and yes i know the meaning of literaly) be kidnapped by a 1980's style cult deprogrammer and held against my will  until they felt I had come to my senses. My own grandmother would report me to the Russian embassy as a terrorist to make sure I am banned for life from entering the country.  I would not be able to reveal what I had done until I returned with a 7 inch scar across my gut, they are that protective and CRAZY, trust me.

So if I can get insurance to cover it here in the US thats the best route for me, but if there is no hope I am going to Dr. Yashkov, aka in my family's eyes taking a 2 week ski trip to my best friend's house in Vail.

One route to consider:

Go with the HMO.  Get a referral for bariatric surgery, go to that doctor, and ask him for a DS.  He will say no, of course, but you will insist, and you will get denied.  THEN you fly to CA and get a consult with either Rabkin or Keshishian, who will give you a dynamite letter of medical necessity, detailing why you should ONLY have a DS.  Then you submit your appeal, get denied again, and then you will get an external medical review, which is more likely than not going to result in your HMO being told they have to cover the DS.  And then the HMO will have to pay for the DS with Rabkin or Keshishian as if it were done in-network.

At least this is how it would work in CA - you should investigate how good Nevada's Dept. of Insurance is, and where they send their external medical reviews of HMO denials of service.

Note that, although the PPO option MIGHT look better, because you have out-of-network coverage, in fact it is no better than the HMO option because of the strict limitation to which surgeon you can use for bariatric surgery, so you may as well use the HMO option, because when you win, you will not have to deal with the much bigger copay.

I have heard of Yashkov - unfortunately, not all of what I heard was good.  I think you can use this link to duodenalswitch.com to find posts about him - but you have to be logged in: http://www.duodenalswitch.com/forum/search.php?searchid=4842 5

You might want to consider spending a bit more for Ungson in MX instead - but I would rather do the insurance route I described above first, and see if you can get one of the best US surgeons paid for essentially entirely.

The PPO, UMR, has the lower copay, $5,000. Health plan of nevada/ United healthcare HMO is $11,000. Both have the restriction to one surgeon in NV. Should I just chose the company with the lowest copay or is HMO easier for appeals? My plan was to go through all of the insurance requirements; 6 month diet, nutrition classes ect, through the surgeon they approve, and once insurance fully approves me for the rny, just appeal for the DS. Thanks. Rabkin would be a dream come true.