Insurance and DS

Hi Ronni, Don't settle for something you don't want. Their are a lot of people who have fought their insurance companies and won. Come over to the DS board for support and info. Good Luck Katie

Ok, I have several things to say and I hope I don't ramble too much. 1.   I still feel DS is the right surgery for me. 2.   I have Tricare Prime insurance (hubby is retired military). 3.   I don't have the means to self pay. 4.   I also don't have months to fight with insurance company. The fight would be worth it, but I'm on           a time limit due to personal reasons. 5.   I spoke with the office of a DS surgeon, and was told by one of the office personnel that my BMI            is too low for the DS. She also said with Tricare, it's set in stone. I still plan on going to the            seminar and try speaking to the doctor himself. 6.   The policy states what is covered and what is not covered. The official DS is not listed in either           catergory, possible loop-hole??? I'll post what my policy says below. 7.   I feel Paul's post was a little off base. I feel he is pushing RNY, and his answers did not         sit well with me. 8.   I am currently being seen by a surgeon who does not do the DS, but was thinking, maybe         I could get all the preliminary stuff underweigh and get approved for RNY, and then speak         with the DS surgeon.  Here are my answers to Paul's commentary: There is always a way to examine any part of the body.  It may not be as simple, but it is not impossible.  What you might want to consider is the frequency of that being necessary, which is extremely low.  There are a number of things in everyone's life that could happen, but no one lives their life preparing for if the do.  For example, you could get struck by lightning.  It happens to more people than you can imagine every year, but do you live your life on the basis that you are going to get struck by lightning? To look at the old stomach, exploratory surgery is required. No I don't live my life according to if I get hit by lightening, however, you are comparing apples to oranges. I'm going to have a major surgery and I must look at all the goods, the bads, and the uglys.  Failure, and the subsequent need for revision, is more a function of non-compliance with the instructions of how to use your new tool than which tool you have.  A DS is not a guarantee of avoiding failure. While a DS is no guarantee against failure, it does have better long term results. I've read the WLS Failure board, and this is what I've noticed. (these #'s are not accurate, just a way to demonstrate my point) For every 100 WLS failure story, this seems to be the theme: 60- Lap Band Failure 39- RNY Failure 1-   DS Failure No one thought silicone breast implants had any long term adverse complications till decades after their usage began, and we all know what happened there. Silicone breast implants are back!! Just as if parents are buying their teenager a car, since they are spending the money, they have the option of deciding that for a first car a corvette is inappropriate and a honda civic is appropriate, the same applies to the ins co and the money being spent for WLS, the cost of which GREATLY exceeds what you and your employer are spending in premiums. The insurance company is a money making business. They are not doing what is right for me, but for themselves. ANY tool is better than NO tool. This is a cop out. That's like saying: Any wife/ hubby is better than no wife/hubby... why settle? Am I not worth the best?  I am a consumer after all, I should be able to get what I think is the best fit.

TRICARE covers gastric bypass, gastric stapling and gastroplasty only when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
• Is 200 percent or more over ideal weight for height and bone structure
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery

TRICARE does not cover:

• Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction
• Biliopancreatic bypass, gastric bubble or balloon, or gastric wrapping or gastric banding for the treatment of morbid obesity

I'm not upset, just stating some facts and hoping to get more replies... Thanks for reading :) Ronni

Good job Ronni. If that personnel is Leah...i have one word for you: IGNORE.  She told me my bmi was too low as well and it was 48! I wont go into details(u can pm me if u want the long version).  Id go ahead and send in the paperwork and get the denial. Then appeal...looks like a fellow DSer has offered u great help (w/ Cigna).   I used to have tricare...they are a little tricky but im sure u can fight them if they cover the rny. Get them to approve weight loss surgery in general...then go after the type.  ps nsaids and the ds are good: I dont want to have to worry about what pills i can tolerate...i want to be the closest to normal (pre) as possible. I can be so close to normal AND lose my weight, be healthy, and have the best long term success. Wasnt a hard choice for me.  I wont settle when it comes to the rest of my life. There is always a way.  If you are willing to fight and wait for it is the real test.

On one of the yahoo groups I'm in, this subject just came up.  One of the posters had revision from RnY to DS and had it paid by TriCare because the doctor coded it as a bowel transection or repair - not the DS code.  So, if you could find a doctor/hospital that would be willing to work with you, maybe that would work some how.  If they could bill it as the sleeve (which should somehow fit in the gastroplasty category) AND the bowel transection . . . . might be worth talking to someone about.

Hi Ronnie, please don't settle for what you don't want -- it could cost you int he long run.  Many have challenged the ins. companies and have WON. It may take longer but it's worth it.  YOU"RE worth it.  I had the DS for the same reasons, and I don't know why someone would think you wouldn't need NSAIDS after DS.  YOU most likely WILL.  OA doen'st go away, unfortunately.  What will happen is  you won't need them as much, but I took NSAIDS as a skinny person, take them WITH NO PROBLEM as a newbie DS-er, and I expect to take them later, but I hope not as frequently. My heart goes out to you -- I know we've spoken before about all of this, but I wanted you to know I'm still here for you and thinking about you and your journey.  HUGS to you, and don't give up fighting for what you want and need, you're worth it!!!

If you email me--I will email you a lawsuit that was won for DS coverage proving that it is not experimental in a court of law.  I am using it for DS approval with BCBS of AL.