Insurance question.... PPO vs. HMO

Hello, I’m looking for help in understanding if my insurance covers a revision to a DS. If anyone has experience with the verbage- please let me know your thoughts. This is for Anthem Blue Cross of CA.
Also, currently I have the HMO plan. Open enrollment is coming up at work and I have the option to switch to a PPO. I am looking for suggestions / personal experience regarding HMO vs. PPO.
Thanks a million!!!!
Revisions: Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, (i.e., unrelated to a surgical complication of a prior procedure) are considered medically necessary when all the following criteria are met:

• The individual continues to meet all the medical necessity criteria for bariatric surgery (see page 1);  and
• There is documentation of compliance with the previously prescribed postoperative dietary and exercise program;  and
• 2 years following the original surgery, weight loss is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight (taken from standard tables for adult weight ranges based on height, body frame, gender and age, an example is available from the National Heart Lung and Blood Institute [NHLBI] at: http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm.

Not Medically Necessary:  Stretching of a stomach pouch formed by a previous gastric bypass/restrictive surgery, due to overeating, does not constitute a surgical complication and the revision of this condition is considered not medically necessary. Investigational and Not Medically Necessary: Malabsorptive procedures including, but not limited to, jejunoileal bypass, biliopancreatic bypass without duodenal switch, or very long limb (greater than 150 cm) gastric bypass (other than the biliopancreatic bypass with duodenal switch) are considered investigational and not medically necessary as a treatment of clinically severe obesity. Repeat procedures for repair, revision, or conversion to another surgical procedure following a gastric bypass or gastric restrictive procedure are considered investigational and not medically necessary when the criteria listed above are not met.

Yes, your insurance does cover a revision to a DS ("biliopancreatic bypass with duodenal switch", which is an exception to the invesigative procedures, so it could be covered) as long as the medically necessary conditions are met.

The criteria are that 
1. Your pouch isn't just stretched out from overeating
2. You still need the surgery according to their criteria (BMI, co-morbidities, see a psychaitrist, whatever it was for the first surgeries)
3. You can prove that you have been eating how your doctor told you to, and have been properly exercising.
4. 2 years or more after your original surgery,
     A. You have lost less than 50% of your original excess body weight
     B. You are still more than 30% over your ideal weight on a standard table, such as the one from the National Heart Lung and Blood institute.

As far as I understand it (and I'm no expert) an HMO makes you stick to doctors in network, and a PPO lets you go out of network for a higher deductable. At least, that is how it was explained to me once. I have a PPO, and I can go out of network, which is a good thing, The only qualified surgeon to do my DS in my state is out of network for me.

Lisa

3. You can prove that you have been eating how your doctor told you to, and have been properly exercising

*How can I prove this? I am worried about this requirement :/

I have been getting regular fills and an am active person, I am not sure how this can be proven. I have been getting fills on and off for the last 6 years. Both my bariatric doctor and my PCP show a long history of weight struggles… PCP even prescribed Phentermine in the last couple of years and I lost weight while on it. This is an indication that the lap band was NOT helping me because I was not losing any weight and needed help.

 Other people know about this better than I do, but I think that if you are seeing a nutritionist regularly, and you keep a food log that you show to her and discuss with her, that would create that proof. You may have to start now, creating that type of evidence.

Lisa

The fact that you policy will cover a band to DS revision is one major hurdle you don't have to deal with.  As long as your surgeon's offce provides detailed documentation as to why your needing a revision is medically necessary you'll be fine.  Of course the revision surgeon will not indicate your stretched your pouch due to over eating. 

As for the PPO vs the HMO, what's most important is knowing if your revision surgery is in your HMO network or not.  If they are, no problems.  With HMO the insurance will not pay for an out-of-network doctor. 

PPO network allows you to use doctor's that are out of network, but you usually have a high deductible and then a co-insurance.

 

BC of CA are *******s.  They will likely fight you tooth and nail about whether you have adequately proved "compliance."  How can you prove that your pouch stretched for some reason OTHER than overeating (e.g., it was improperly constructed in the first place - which ALL pouches are, by definition, in my opinion)?

Here's the thing about the HMO vs. PPO, especially in CA.  There are only two or three DS surgeons who are in-network with BC of CA - and Keshishian is the ONLY one who I would use for an RNY to DS revision.  Depending on how your "in-network" group is defined, however, Keshishian MAY not be in-network for you anyway.  If there is no DS surgeon in-network and you have an HMO, BC HAS to pay for a surgeon who is out of network.  However, they may try to foist you off on a non-DS surgeon, or one of the other DS surgeons who are not RNY to DS specialists.  So you will have a fight on that issue on your hands.

On the other hand, the out-of-network reimbursement rate usually SUCKS.  If you can force them to let you go to Keshishian with an HMO, I would stick with that route - your out-of-pocket costs will be much lower.  But if the money isn't an issue, a PPO would probably be easier, surer and quicker access to Keshishian.

But your big hurdle is going to be meeting their arbitrary and capricious requirement to "prove compliance" in the first place.  Go buy yourself a bucket of patience - I'm betting you're going to have to appeal to the DMHC.  After you get denied the first time, you should plan to get a self-paid consult with Keshishian to get him to state that you didn't stretch your stomach because of non-compliance.

In the meantime, you need to gather the other documentation needed to establish you meet their requirements, including any exercise regimens and some sort of showing that you followed the guidelines you were given, records of your compliance with your crapband surgeon's recommended eating and other requirements, and look over your medical records for smoking guns where you admitted to your surgeon or PCP that you were not following the crapband rules - because BC WILL use them against you.  You need to be prepared to rebut their "reasons for denial" and make whatever pre-emptive explanations you can ("my doctor tried to convince me it was my fault, and I pretended to agree with him in order to avoid an argument about whether giving me a crapband in the first place was the issue").