Insurance Issues VSG, DS 8 years later

Hi everyone,

I was also very active on these boards 8-10 years ago. I won't share the long story, but the short version is that I need a DS and my surgeon agrees, robustly! My concern is about my insurance. I have BC/BS of Florida (even though I live in MA, dh's company is in Florida). Has anyone had a problem approaching insurance for a second WLS? What kinds of issues did you face and how did you get an approval? My hunch is that my calling will do nothing, but my surgeon and insurance department at her practice will get results.

Thoughts?

Thanks!

Hi there

I have tricare prime and they paid for my crapband which of course failed miserably. When I started pursuing the DS I was denied and told only one WLS. I considered adding additional insurance but during that time, 2012 the DS was not covered by many.

Ultimately, my surgeon agreed to give me a smoking deal as self pay to remove the band, repair a hiatal hernia and a DS for $12K as he was trying to get more DS procedures on his resume.

Absolutely no regrets, love love love my DS. I'm very fortunate in that I pretty much eat whatever I want and hold around 150 to 155. If I watched my carbs I'm sure I could get down but at 5'8" I'm pleased.

I do think having your med to the calling is smart. Tons depends on BMI and co morbidities

Blessings

Julie

When I saw my surgeon about this a year ago, the insurance denied me. I didn't appeal at the time, life was too crazy and I hadn't faced the orthopedic crisis I'm now facing.

When I saw her last week, she could see very clearly that I am having severe joint problems: I had a total knee replacement in July 2018 w/ a very difficult recovery, and will have to have to have the other knee down. I also have unrelenting lower back pain/herniated discs. Finally, there are studies linking MS (which I also have) and obesity. So, best case, my surgeon can advocate and we'll be fine. Otherwise, I think my ortho doc and neurologist will get on board.

Also, I asked my insurance company online if I qualified/am eligible for WLS at this time and got a yes, in writing.

You have to start with a surgeon who is able to do a Hess DS and who agrees you need it. You don't want to be approved for a surgeon that doesn't do DS. The opinion of your GP is important if their records document every interaction that proves your ongoing disability. There are two arguments that might be successful. You and your surgeon could say this weight-loss surgery should be a covered expense because it is treating your orthopedic disability, which wasn't corrected by the previous procedure. In other words, it is a treatment for severe osteoarthritis, not weight. (It would be good to say it was also needed as a treatment for unresolved diabetes or hypertension or depression in addition, if you can and it has been documented over the years, and that the first procedure didn't work for those either. If that's true) If that doesn't work, you can try another argument, which is that the failed procedure has the potential to cause serious gastrointestinal issues including cancer or kidney failure that are in their beginning stages if not corrected (which would have to have been documented in your GP's files) such as esophageal damage from frequent vomiting or if you have had symptoms of reflux, or multiple episodes of dehydration, etc. The point of both arguments is that the new surgery is to treat or prevent something else because of a failed procedure, not for obesity or weight-loss. Turn your attention away from weight, but to other aspects of your health from the failed procedure. Good luck!

The only vetted DS surgeon I know of is Dr. Dennis Smith in Celebration FL. To find out what is covered, get a copy of your explanation of benefits. If there is a one-per-lifetime rule for wls, it will be in there. It should also tell you what procedures are covered. If you are not seeing Dr. Dennis Smith - do make sure that this surgeon does an actual DS and not one of the hybrids (SIPS, SADI, LoopDS). Some of the unscrupulous surgeons will code them as DS to get you covered, but you are at risk if anyone reads their surgical report closely enough to notice that the details (one anamastosis instead of two) are not that of the approved DS. If insurance does notice this and refuses to pay for the surgery, the surgeon and hospital can sue you for that amount.

She's having it done with Sheila Partridge, MD, Center for Weight Loss Surgery, Newtown-Wellesley Hospital, Mass