SLEEVE EXPERIMENTAL???/////

Hi everyone.  I wanted to pass some info along and see if anyone has had a simular experience?  I work for a huge company that has a pretty general rule for paying for WLS.  It reads WLS is covered for morbid obesity.  I was like yes, no problem.  Untill my predetermination came back denied.  The reason for the denial was that the surgery is deemed EXPERIMENTAL.  What bull is that?  I've heard of a ton of people getting the surgery approved thru the appeals process.  So what do I need to do?  Try to proove that the surgery is no longer experimental.  It seems to me once someone else sends in there appeal and gets them to go ahead and approve the surgery that they should go ahead and approve everyone else.  If the only hold up was that EXPERIMENTAL word.  Ugh that frustrates me. So, I wanted to see has anyone else been denied just because of the word experimental, then appealed to have them approve the surgery?  My deal is I don't know where to start.  It seems like there is so much info out there.  I know I only get two appeals.  What if I don't send in enough or the right info?  I thought about getting a lawyer.  Has anyone gotten a lawyer to appeal on there behalf for the sleeve?  Did they get it approved?  Let me know.  I'd appreciate any advise that you can pass my way. 

Unfortunately we are on the cusp of it being removed form the experimental stage, but not yet. There's been a position paper submitted to ASBS to have it removed as some EXCELLENT 5 yr data has been coming in. Usually there is a 5 yr wait for data to determine safety and effectiveness before it is no longer considered experimental. So once this proposal is accepted by ASBS, expect many of the insurances so start covering it like they do the others. There's also the fear by the insurance industry that they'll run into the same problems they did with the LAPBAND. Because it was pushed through to approval before the 5 yr data was in (thanks to the HEAVY push by the medical company that makes it), they are now seeing all ytpes of problems with it's safety and higher complication rates they further out the pt is. They spend millions on surgeries to fix or remove a slip, eroded, infected band, and many of those complicated cases end up getting revised to the Sleeve or RNY anyway. The safety thing isn;t an issue with the sleeve, as it has been proven and practically complication free as part of the DS and as a treatment for ulcers and cancer for decades. But no one studied it as a stand alone procedure until recently, when the DS pts (usually >50 BMI) who needed surgery done in two stages, weren't coming back for the bypass part because they lost so much wt with just the Sleeve. So now that 5 yrs of wt data is showing it to be almost as good as the RNY, and far superior than the LAPBAND in terms of wt loss (and without all the complications associated with the RNY and Band), you can expect that the ASBS will add it to the list of approved surgeries soon. Many insurances, including Medicare, are already starting to cover it. But some insurances are behind the times, and aren't up on the bariatric community's push to make the Sleeve a standard. But  a lot of people getting approved do it on the appeal. The first review is usually by someone not authorized to make exceptions (and may be looking for reasons to deny). The appeal is usually with a doctor who knows more. Plus, with the appeal, your surgeon will submit all the published articles and extra justification for approval. Plus more docs are performing the Sleeve. Last year, only about 50 surgeons (usually ones that already performed the DS) were doing the Sleeve as a stand alone procedure. Just last fall, close to 350 surgeons were trained in the procedure who want to start offering it as well. Some docs think it will replace the LapBand (not without a fight by the company that makes it though!), and may be preferred to the RNY for BMI 35-50 who don't really need the bypass part. You should make sure your surgeon has a good insurance person to submit your appeal, and ask if they have all the studies. If not, you can submit them yourself, along with the position proposal to ASBS to have it approved. This paper, the research articles, and examples of appeal letters by other Sleevers can be found on VSGFAQ.com. Don't give up. Don't let your ins co dictate the right surgery for you. You don't want to get pushed into something that has more complications. Good luck, Kahlua