Insurance Denial

Valerie,

I think there is a "new" person on the DMHC in CA who is NOT DS friendly at all, this just happened recently. Not sure which Pre-Op it was, but someone was recently denied.

AND of course, the person who posted about that is no longer allowed to post here. (In fact, I think her posts have been pulled.)

S~

 This website recently got many of the most dedicated "pay-it-forward" WLS veterans angry, and we have started a new board. Please join us at weightlosssurgery.proboards.com to get input from happy, healthy and successful WLS veterans regarding information you NEED to know before you make one of the most important decisions in your life. This site is beholden to commercial interests - ours is not.

Hi there...I'm afraid unless you are prepared to self-pay, there is no way around it.  I too am having a terrible time getting approved for a revision surgery to the DS. Denied 3 times, now an 'independent' review board has my fate in their hands.  My BMI is 35.2, with several co-morbidities.  This is the kicker: When I was 15 lbs lighter, my doc said that, even though I had regained most of my weight,  in order to be considered for revisional surgery I had to meet the qualifications again.  I didn't weigh enough! Eventually, of course, I did. So when we finally put in the request, I totally expected approval.  Instead, do you know what they said??? Since I had REGAINED  my weight, I proved that weight loss surgery did not help me and proved I was noncompliant with a diet!!!!  Grrrrrrrr!  Catch 22.  If I hadn't gained enough back, I couldn't get the revision because the lapband was semi-successful; once I had gained back the weight, then "I" proved wls didn't work for me.
I was furious.  Still am... As my doctor has said, the lapband failed ME - not the other way around.
I'm holding my breath.  I have been fighting this battle for way too long to give up.

I urge you to check out the link in Cbramsey's post, just above yours. There are people on that new board who can, and will, help you fight your insurance company.

Thanks! I have been doing just that most of the evening. The fight is on.  It's my life at stake.

 BMI should be 38 with at least one comorbidity or 40 with none. GERD doesn't count. Get checked for sleep apnea and diabetes. Or just have some pickles and chips with a ton of water and then get weighed the next day.  I'm in CA too and as long as your insurance doesn't specifically state that bariatric surgery isn't covered, you should be able to do it.  If you have to wait a year it'll be worth it.\

Sheri

NIH/Medicare guidelines:

NIH:

Currently, bariatric surgery may be an option for adults with severe obesity. Body mass index (BMI), a measure of height in relation to weight, is used to define levels of obesity. Clinically severe obesity is a BMI > 40 or a BMI > 35 with a serious health problem linked to obesity. Such health problems could be type 2 diabetes, heart disease, or severe sleep apnea (when breathing stops for short periods during sleep).

Medicare:

Nationally Covered Indications
Effective for services performed on and after February 21, 2006, Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who have a body-mass index > 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. These procedures are only covered when performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006).

I see 35 BMI NOT 38 BMI as the low end...

Liz

 Interesting!  Is that in CA too? Kaiser said 38 and I believe Keshishian said so too but I could definitely be wronge.  Thanks for setting me straight!

Sheri

Those are the NATIONAL NIH/Medicare guidelines and last I looked, CA was still part of the US. However, since I don't live there, I'm not positive and the one who can answer is no longer allowed on this site.

 Everything I'm reading agrees with what you posted.  So you're right unless somethings changed recently.  Darn Kaiser--such liars.