For anyone fighting insurance claim that DS is "experimental"

first... go here and print the page for yourself... http://www.ama-assn.org/ama/pub/category/print/3882.html (actually, it's about 9 pages) THEN.... copy and past if you wish, or write your own letter:

            Attached directly to this letter, you will find a copy I have made of a page from the website of the American Medical Association (AMA).  The website, if you wish, can be viewed here…  http://www.ama-assn.org/ama/pub/category/3882.html

            The AMA is the association who came up with the use of the “Current Procedural Terminology” (CPT) codes that are in use today.  The use of CPT codes makes it easier, more efficient (and more error-proof), in communication between doctors, hospitals, insurance companies, etc… it provides a standard nomenclature to document medical services and procedures.  Being an insurance administrator, I am sure you are well aware of WHAT they are and how you need to use them if the process of your daily work.

            Something that you apparently do not know (which you should) is what the CPT codes can tell you about that given procedure.  The attached copy from the AMA website goes into much more detail, but in summary, if a procedure is assigned a FIVE-DIGIT NUMERICAL CPT CODE, then that procedure is a “Category 1” procedure, and NOT considered by the medical community to be “experimental” or “investigational”.  To repeat, the procedure I am seeking is formally known as “Biliopancreatic diversion with duodenal switch” (commonly called “Duodenal switch” or “DS”)

            The CPT code for the Duodenal Switch procedure is 43845 which is found in the AMA’s “CPT Assistant”, volume 15, issue 5, May 2005 and is described as 

            Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)

            The AMA requirements to be assigned a category 1 CPT should, by themselves, be sufficient to prove to you that this procedure should NOT be considered “Investigational” or “Experimental”. Gary, or whoever moderates this board.... any way to possibly "sticky" this at the top for a little while? I'm hoping this (along with my 200+ page assault) will help ME... might as well help you too if it works.

Thanks...this may end up helping me...at this point in time I was just wanting a revision to my  RNY, make pouch small and stoma tighter, since BCBS won't cover banding or DS. But they are saying there isn't enough proof of mechanical compications for  revision....me just not losing more than 50% of excess in the past 3 years despite being compliant with diet and exericise isn't enough for them and my BMI is still 52. However, had I had a VBG and had the same thing happening I would get a RNY without having to prove complications just be 2 years out, not lost 50% and been compliant...but they leave no option for the RNY patient...so I am going to argue that they since they need to do the revision or offer the DS....