Revision Insurance Question, specifically Highmark BCBS (xpost)
hi! I went to a WLS seminar tonight as required by the surgeon I'm wanting to work with on my revision. As we arrived, the insurance specialist gave us a handout specific to our individual insurance carrier with required procedures and documentation, procedure codes etc. I have Highmark BC/BS PPO Blue and right on this handout it states "Revision Surgeries are no longer covered by Blue Cross/Blue Shield for Weight Gain.
Has anyone recently had a revision with this insurance? if so, how did you get around it?
one of the offices requirements is that we all call our insurance company to see if the different surgeries are covered under our plans (they gave us the diagnosis and procedure codes) before we move forward...so I know if I call and say I want to know if a revision is covered, I'm going to be told no. I don't want to just ask about the specific procedures without mentioning a revision, because I don't want to have to go through the other requirements (Upper GI, U/S of gallbladder, nutrition consult, supervised diet for 6 months) if in the end I"m going to be rejected ...
the insurance specialist said that not all revisions are denied, it's only denied if the only reason is due to weight gain, so if there are medical issues necessitating the revision or open staples etc. (I had a VBG in 1998), etc, the revision surgery might be approved....so I need to know the right terminology to ask when I'm contacting the insurance company.
anyone with any experience in this that could help me out?
Hello!
I do not know about revisions, but I do have Highmark. I am sooooooo sick of dealing with them, let me tell you! Read this from Highmark's policy:
Repeat or Revised Bariatric Surgical Procedures (43771-43774, 43848, and 43886-43888)
- Conversion of a gastric restrictive procedure without gastric bypass (e.g., laparoscopic adjustable gastric banding, or vertical banded gastroplasty) to a gastric restrictive procedure with gastric bypass (e.g., for morbid obesity)
- Revision of a failed gastric restrictive procedure (e.g., restapling of dehisced vertical banded gastroplasty staple line, severe adhesions of the gastric pouch, stenosis of stoma, dilation of stoma) A Roux-en-Y gastric bypass (43644, 43846) may be considered medically necessary for patients who have not had adequate weight loss (defined as loss of more than 50 percent of excess body weight) from the primary bariatric surgery (e.g. laparoscopic adjustable gastric banding (43770), vertical banded gastroplasty (43842). Since, maximal weight loss is not typically achieved until 1 to 2 years of the primary bariatric surgery (e.g., laparoscopic adjustable gastric banding, or vertical banded gastroplasty), a Roux-en-Y gastric bypass is considered not medically necessary and not covered if performed within two years of the primary bariatric surgery. In addition, a Roux-en-Y gastric bypass following laparoscopic adjustable gastric banding or vertical banded gastroplasty is considered not medically necessary and not covered for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the primary bariatric surgery. More than one laparoscopic adjustable gastric banding, vertical banded gastroplasty or Roux-en-Y gastric bypass procedure is considered not medically necessary.
I think you just need to make sure you have a dr say you need this surgery for another reason besides just weight gain from noncompliance. You need more of a VBG malfunction or scar tissue or something. Then you should be fine. Go to the revision board and ask about this weight gain revision exclusion and I'm sure someone will jump in and tell you what you need to know to get insurance to cover it. Good luck!!
Mandy ***See my blog for appeal info***
Thanks for the info Mandy, I did get to speak to someone today at BCBS and she told me that if the surgery was deemed medically necessary it would be approved and she even gave me some reasons why it could be deemed medically necessary. So I'm trying to get a script now for an Upper GI to start the testing. Thanks again!
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