Blue Cross of MA won't cover ROSE procedure

I was accepted into the study for the Rose procedure @ Lahey, had my endoscopy and found that both the stoma and pouch are way too big, and I still have another 100 lbs. to lose (lost 130 already) BCBS denied saying that it is too experimental. Then I found out that I was not needed for the study anymore that they have enough already...  I had RNY with a lot of complications back in 2002 and I am terrified to go under the knife again for a revision... I just want to finish what I started but I don't know which way to go... Any advice?

I have some advice - APPEAL, APPEAL & APPEAL!  I'm not sure that it will work for you, but fighting diligently will help you or someone else in the long-run.  Also, I am not sure what the ROSE procedure is, but Dr. Thompson does endoscopic revisions at Brigham & Women's in Boston.  I'm going to see him in a few weeks.  I'm not positive that my insurance will cover the procedure he does, but I'm ready to fight, fight, fight! Do you qualify for a revision under your insurance?  You should be able to get a policy notice for gastric bypass surgery that tells you if you qualify.  If so, try to find out which revisions they WILL cover.  If you can prove to them that you have a better, cheaper, less-invasive approach that does have statistics behind it, they may agree.  That is certainly my plan. Best wishes to you. Kathy

Hi Kathy, I did appeal and they wrote to tell me that they will cover approved revisions but nothing that is a clinical study... My surgeon said that the reason that the insurance should cover it is because they consider it a failed surgery that needs to be repaired. I can see why BCBS wouldn't want to be involved if it a procedure that has not yet been approved though... my dilemma is that I had so many complications with my original surgery, mostly bleeding issues that lead to other problems that a traditional surgical revision seems much too risky for me. I was so thrilled at the possibility of a less invasive approach.  I haven't yet researched every avenue yet, but I sure would like to take the least invasive that I can...  Thanks so much for the info. good luck to you too, Lisa

HI Kathy, I am also seeing Dr.thompson . I was one the Sham subjects in the Restore trial >>I am haveing the real deal done on march . Just wanted to say hi to a neighbor in Northampton Ma, when do you see him next?   kim

Hi Kim, I'm seeing him on March 10th.  They are treating me like a new patient - even though he did the UGI and the Endoscopy.  I was so bummed when I found out I couldn't be in the trial - after the endoscopy, they said I totally qualified, but the next day with the UGI, they found a small fistula.  I'm just hoping that my insurance will cover the procedure - and I'm ready to fight! Northampton is not too far at all.  My husband and I go up to Greenfield, North Hatfield regularly in the summer, we work with the migrant farm workers, also, we used to live in Springfield. Best wishes when you get the "real deal".  I must say, I'm jealous - but happy for you!  God Bless, Kathy

I'm confused.  If the ROSE procedure is a clinical trial, why would your insurance even get involved?  I'm having the RESTORe procedure this thursday and no insurance has been involved at all.  Unfortunately they are no longer enrolling for the RESTORe study. Betsy

Hi Betsy, the surgeon said that it was a failed original surgery that needs to be repaired and they have to go through insurance for that. I guess I will have to find something that I can either afford or try a different approach.  I don't know much about the RESTORe procedure yet, just reading up on all the possibilities.  I hope some of these less invasive procedures get approved soon! I wish you the very best on Thursday! Lisa