Insurance and DS

I have a question. My insurance will cover RNY but not DS. I was wondering if anyone had same problem but was able to get insurance to make an exception? I know the reasons the DS would be better for me. 1. I have osteoarthritis and will be unable to take meds for it if I have RNY. 2. I worry about the main stomach becoming diseased and no way to exam it if I have RNY. 3. I want to have this done once. I don't want to have RNY fail and then have to have a revision. Can't be sure insurance would even cover a revision. 4. I want the best long term results available (DS). Thanks for any and all replies!  Ronni

Aetna choose to deny my request for a ds, although they approved it for a co worker two years earlier who had the same medical restriction i so, who also cannot have a rny, my co insurer tri care chose to stop covering the ds the day before i applied for the ds. what a coincidence. Nine bariatric surgeons reported to both insurers that the DS was the only option due a condition physical condition. Their delay has cost them, and me a heart condition and my employment, now fully retired at 57, at full pension to my employer and the taxpayers and 100k in medical expense to Aetna, which cured the heart ailment. and now they will approve the ds and will pay for that too   they paid for all of the nine consults.  and all of the pre opt, and aproved the RNY, they paid the legal expense for the appeals, Tri Care had a 9month appeal and a congressional hearing on my behalf with the Secretary of defense General Granger. over this issue, the Government is resposible for why I cant have a RNY,,  STILL pending 3years later. but fortunately just margingal on the weght, its about diabetes that the DS is so important. and that RNY just doesnt cut mustard,

Hi Ronnie, And a big resounding YES, I was able to fight CIGNA for the DS and I WON!!  You have to be diligent, informed, and most of all DO NOT GIVE UP!  That's what your insurance company is hoping you will do. Your reasons for wanting the DS are basically the same as mine.  And don't let anyone tell you to "just settle" if the DS is what you truly want. If an insurance company will cover the RNY there should be no reason for them NOT to cover the DS.  Most insurance companies will deny the DS because they will term it "experimental/investigational" when, in fact, it is not.  Medicare now covers the DS and we all know Medicare won't touch ANYTHING remotely close to being experimental.  I fought with CIGNA for 8 months before I was approved through an external appeal with Hayes, Inc.  And by the way, the DS has been around for about 20 years and there is substantial evidence through studies showing it is effective and most definitely not experimental anymore. Have you chosen a DS surgeon yet?  Have you been to the DS board here on OH?  Definitely visit us there if you haven't already.   My advice is to make sure you get everything in order to be approved for WLS so the ONLY denial reason you will receive is for the DS.  That will make things go much smoother for you.  Then, let the fight begin.  I have all the information I submitted to CIGNA and I will be more than happy to help in any way I can.  Just let me know when you're ready to appeal! The DS is so worth the fight, so don't give up!  You will get there and it will be so worth it! Oh, and by the way, the Yugo sold several thousand cars while it was sold here in the US, and it got everyone to where the wanted to go... for a while.  Now how many of them do you see on the road?  But you still see the Corvettes and the Mercedes purring along, don'tya?

Hello Paul, I guess we are just going to have to agree to disagree.  But I do feel your posts "take what they offer and run with it" are insulting and, in general, not helpful at all.  And while you say you do not push one surgery over another, that is not what it seems.  I'm sure your reasons for choosing the RNY were very well thought out and you chose the WLS that was right for you, just as those of us who have researched all WLS and have chosen the procedure that is right for us - the DS.  Your recommendation to take what is offered is ludicrous.   If I had taken your advice I would have stopped fighting, but because I chose to go against your "advice" I came out the winner and am scheduled for the DS on Oct. 3rd.   And as far as "numbers done" on the DS, maybe you should do some more research yourself to see how many have been "done."  I'm sure the numbers would surprise you. Also I'm sorry you seemed to have gotten so caught up on the car analogy.  Seems like you have a lot of time on your hands to nitpick over it. I try not to sugarcoat my fight with CIGNA at all, and I am upfront about the number of appeals I had to go through and the number of months it took to get the approval letter, but I would NOT tell anyone not to fight for what they want and just settle.  Since you are such a fan of analogies, I guess it's a good thing our country's revolutionists didn't decide to just sit back and take what the King of England was offering (after all he was the extreme authority figure that was deciding what was in the best interest of the people), and even though it was a matter of life an death to oppose him, many chose to fight for what they believed was in their best interest, and even tho' it took lots of time, they, too, won!  If everyone just sat back and accepted what was offered, we wouldn't be where we are now.  After all, candles offered light for a fraction of the cost of electricity, and no one ever got electrocuted unless they were actually hit by lightening.  Damn that Edison for going against the grain and not taking "what was offered!"

I agree with Lyndia, be sure you have surgeon that BELIEVES in the DS, and get through all the preliminary hoops for approval for WLS, and then move to the insurance issue.  Who is your insurance carrier?  I thought I remembered seeing you post somewhere before, but I'm not finding the posts.

Don't settle for anything. The DS is not experimental and a lot of people have fought their insurance and won. I won't bore you with all the stats since you prob already know them, but the DS has been proven to produce a larger weight loss and a much smaller chance of regain. That was enough for me to choose DS but there are many other reasons. Please do come over to the DS board and ask this question-of course they will all answer to fight it but you will get some great info tere too. hugs-Amy

What does your insurance cover? Have you tried to appeal a decision to not cover the DS? Sometimes people do fight denials and end up with the proceedure of their choice. It may take a while, I sincerely hope your health holds up for the fight. That is something I think insurance companies fail to take into consideration, that weight loss surgery is a time sensitive issue, and if you have to keep waiting and fight them, you may die. Or maybe they do take it into consideration and keep denying over and over hoping you either go away, take what they cover, or die. Get all the information you can about DS and why it is a good medical solution FOR YOU. The features about DS that aply to your health, and what you need to become less of a health risk to them. As for RNY failing, one point is that any surgery can work for you, if you follow your surgeons' advice, and any surgery can fail you, if you outeat the surgery's limitations. I'm sure for you, your concerns are valid, and you know what you want. I wish you all the luck in the world.