insurance will not cover ds only rny any suggestions

Has anyone been switched from the sleeve to the rny?  if so how did you make out?  my dr is in nj and the bcbs of horizon will not pay for my ds.   so i dont think i can appeal because they came flat out and said its not covered.  i am waiting 3 weeks now for them to cover my rny paperwork was sent in 4/29/13 and i am still in pending.. my surgery date is june 10th... plus had a blood clot back in jan and i am afraid of having this surgery.. any thoughts would be appreciated. thanks

The first thing to do is actually read your policy and see how the exclusion of DS is worded.  Insurance companies will sometimes cut a few corners and just tell you what they want.  Because they KNOW you will not read the policy.

my insurance is bcbs of pa.. the code the dr gave me is a covered code...but since he is in nj they bcbs horizon of nj is telling me they do not offer that as a covered surgery.. so im confused how one can cover it and the other does not.. but i have argued with them and they nj are not budging..

I had a similar situation, but my Horizon was of NJ and I wanted to go to PA. Because I didn't have any "out of network" benefits, they would not cover the DS or any other surgery for me. I ended up finding Dr. Greenbaum and didn't pay a dime out of pocket! Best of luck to you! These insurance companies are real stinkers and they want you to follow their rules!

Erin

I have Horizon BCBS and they covered a Lap-Band and then a revision to a DS and I was a "lightweight" with a BMI of 41.  

If you fit all the criteria appeal, its worth a try!

BCBS in general doesn't WANT you to go out of state if they can avoid it.

While my DS was covered, my surgeon was not so I was on a third level appeal when I found ONE surgeon IN state who could do mine. But what I had to do was call every office IN the state and ask if the 1) took my plan 2) did a DS and 3) did the DS ON a lightweight. Then I documented in a spread sheet who I talked to, what day, what time, etc. I literally was on my last option when my current surgeon agreed to do it.

Re-read your policy VERY carefully. When they said it was not covered, did you think to ask where in the policy that was stated?

Liz

I'm from NJ, and was (one) the test case back in 2006.  I sued BC/BS to cover the DS, when they claimed it was experimental.  I went 'pro se', represented myself....  halfway thru the case, it got dismissed, because BC/BS had revised their policy and no longer considered it experimental.  They put criteria in place, but it IS a covered service since then.  I know a few other NJ BC/BS folks who have had it covered recently.  Don't settle for any surgery you're not sure of.    Your specific policy may exclude WLS, but you'll have to read it.  but, BC/BS of NJ does pay for it in certain policies.  Mary

Trust no one. You MUST read your policy yourself. There is simply no substitute for this. Any company employee you speak with on the phone can provide misinformation, either because they don't understand the details of your policy or because they can't be bothered to read through the details.

Even if your policy doesn't cover the DS, or covers it but won't agree to you going out of state (even if there is no DS surgeon in state), or only for a certain bmi or whatever, these are all issues that can be appealed. If you are not willing to learn for yourself the truth of your policy and do appeals if needed, you choice is to be stuck with the operation you don't really want for the rest of your life.

No one should care about this more than you. YOU need to care enough to make the effort needed to determine what your policy realy says and then do appeals if needed. Your future depends on this.

Larra

thanks for all your replies..

It also depends on what your employers policy covers. So just because an insurer offers it is no guarantee your plan covers it.