My insurance won't cover DS because they claim it's investigational

I have some questions for people in the know.  I don't know how to proceed from here, so any advice would be wonderful.  So far I have done my research, and have finally decided DS is right for me.  So I read my insurance coverage on their website (Wellmark Blue Cross and Blue Shield of Iowa) but needed clarification.  I knew that Lap Band and Roux-en-Y were covered because some of the people I work with have had these procedures.  However, they listed DS, but I didn't understand what they meant.  So I called my insurance company and asked them if DS is covered, and they told me it is considered investigational, so it is not covered.  Now, my question to you is--what now?  I'm not sure if I should still proceed to try and get a letter from my PCP, then make an appointment with my surgeon, and if the insurance received a letter stating it's necessary it would be covered, or if I need to stop at this point and try to convince my insurance to cover DS before I move forward.  Any help/advice/comments would be greatly appreciated.  This has got me really down now that I finally made my choice to be told, "well, you could get this other surgery done that you don't really want, or nothing".  Thanks. -Tara

Welcome to the club!  Mine won't either. Ideally, you will get denied for the DS and should be able to win on appeal.  I don't know all the ins and outs.  I see LeaAnn is on your friends list.  She is the one to ask.  I would pm her and ask her.  She knows which states have a Dept. of Insurance that will overturn insurance company's denials and which states don't.  I am not sure if you should try and get approved for the rny first and then try and get them to cover your DS, or just try for the DS to begin with.  Again, LeaAnn will have the best advice. Make sure you have done everything to meet the criteria of your insurance company.  I don't think you stand a chance at convincing them that they should cover the DS.  Just do all of your hoop jumping and then go from there. Everyone says the DS is worth fighting for.  I have yet to find out, but I am still fighting. Good luck!

Here is the medical policy for Wellmark BCBS  see the highlighted areas and my remarks with them  I hope this is helpful with your understanding their medical policies. 

Surgery for Morbid Obesity* Printer-Friendly Version   

 

Medical Policy: 07.01.17  Original Effective Date: September 1995  Reviewed: November 2007  Revised: October 2007 

 

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

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Description: 

Obesity is the most frequent form of malnutrition in the developed world and it is increasing. Morbid obesity (i.e., obesity with secondary serious or debilitating progressive disease) is generally associated with a body mass index (BMI) of ≥40 kg/m²  (i.e. weight/height squared). Morbid obesity has a significant impact on cardiac risk factors, incidence of diabetes, obstructive sleep apnea, debilitating arthritis of weight bearing joints, infertility, psychosocial and economic problems and various types of cancers, etc.

The first treatment of morbid obesity is dietary and lifestyle changes. When conservative treatment fails, a few patients may require a surgical approach.  A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as those who meet the following criteria:

• Patient has a BMI of 40 kg/m² or greater than 35kg/m² in conjunction with severe comorbidity such as cardiopulmonary complications or severe diabetes
• Super obesity described as BMI >50kg/m²
• Failure of sustained weight loss with supervised dietary and conservative treatment over the years
• Motivated individual with acceptable operative risk

Surgery for morbid obesity, also known as bariatric surgery is based on intestinal malabsorption and gastric reduction. Surgery is considered successful if weight loss is maintained at greater than or equal to 50% of excess body weight for more than 10 years.

Several different gastric reduction and intestinal malabsorption procedures are listed below:

Gastric reduction (gastric restrictive) procedures:

• Vertical-banded gastroplasty
• Adjustable gastric banding
• Gastric bypass (Roux-en-Y gastroenterostomy); this can be done by both open or laparoscopic approach
• Laparoscopic silicone gastric banding
• Mini-gastric bypass (laparoscopic)

Malabsorptive Procedures:

• Biliopancreatic bypass (Scopinaro Procedure)
• Biliopancreatic bypass with duodenal switch

Policy: 

Prior Approval is recommended for this service. 

The following surgical procedures for the treatment of morbid obesity may be considered medically necessary when the criteria listed below are met:  These are the ones that they will consider with preauthorization

• Vertical-banded gastroplasty
• Gastric bypass (Roux-en-Y gastroenterostomy) with short Roux limb equal to or less than 150 cm; this can be done by both open or laparoscopic approach 
• Adjustable gastric banding (Lap-Band® procedure)

Criteria for Coverage:

• Patient is at least 18 years old

And

• The patient must have a documented medical history of failure to sustain weight loss with medically supervised dietary and conservative treatment for at least three years including within two years preceding surgery. Medically supervised treatment consists of physician documentation of the assessment of the patient, what health interventions are prescribed and their on-going assessment of patient's progress toward a goal of weight loss or control of an obesity-related comorbidity.

And

• The patient must be a motivated individual with acceptable operative risk and must be evaluated by a licensed mental health provider to determine the patient's willingness to comply with pre and postoperative treatment plans, and a strategy to ensure cooperation with follow-up must be documented.

And, in addition to the general requirements above, the patient must also meet one of the following weight criteria:

• BMI of 40kg/m² for at least 3 years  

Or

• BMI of greater than 35kg/m² in conjunction with at least one of the following:
  • Hypertension requiring medication for at least one year
  • Diabetes Mellitus type 2 requiring medication for at least one year
  • Obstructive sleep apnea, confirmed by sleep study, which does not respond to conservative treatment
  • Documented cardiovascular disease
  • Pulmonary hypertension of obesity

The following surgical procedures for the treatment of morbid obesity are considered investigational:

• Mini-gastric bypass (laparoscopic)
• Biliopancreatic bypass with duodenal switch ( its in black and white)
• Laparoscopic silicone gastric banding
• Biliopancreatic bypass (Scopinaro Procedure)
• Long-limb ( > 150 cm) gastric bypass

Subsequent bariatric procedures, including revisions, in patients *****gain weight due to failure to comply with lifestyle or dietary modifications are considered not medically necessary. 

I believe that Medi-care has removed the investigational label from the DS so it would seem to me that you ought to be able to refute that aspect of the DS exclusion.