VSG Denied by Federal BCBS

After a 2 month wait I was denied by Federal BCBS for VSG.  My letter states, "We could not approve coverage of this service because you did not meet the medical necessity criteria required for coverage of a laparoscopic sleeve gastrectomy.  Coverage was denied because this procedure has not been scientifically proven to result in improved net health outcomes for morbidly obese patients." Does this make sense?  In the first sentence it sounds like VSG's are covered but that I did not qualify.  And then in the second sentence VSG's are not covered?! I plan to appeal.  If anyone has any thoughts/ suggestions/ advice I would love to hear it. Thanks, MJ

Here is some information to look over that might help getting it looked at 

how to go about insurance approval and appeals. I know this can help the sleevers cause we have the same problem with the turndown due to "unproven", investigational outclause by most insurance companies. Here goes:I have received a number of inquiries lately about how to deal with this insurance stupidity, so I thought I would post it here rather than repeat it over and over in PMs, since the general process is pretty much the same for most insurance companies.* First, figure out if your insurance company covers WLS at all. You can usually find this on the insurance company website.* If they do, get a copy of YOUR policy to see whether they cover WLS, as employers can opt out of certain coverages. * If they do, find out (from your HR department) whether your insurance plan is fully funded or self funded. It makes a difference in your route and right of appeal.* If you find out that the insurance company covers WLS BUT says the DS is experimental/investigational, this is what I have found is the way to proceed:* Ask your PCP to refer you for WLS, and be a good little sheeple and follow all the rules. Don't mention your desire to get the DS at this point. * What you are trying to do FIRST is to get yourself approved for WLS in general (likely the RNY), so that when you start to fight for the DS, you are only fighting for WHICH surgery you should have, not whether you qualify in the first place. If you start out asking for the DS with a company that has an exclusion of the DS in their policy, they will make your life miserable at every turn to try and keep you from getting approved for WLS in the first place -- they will get hypertechnical with the 6 month diet requirements, with the proofs of being MO for 5 years, etc. They are generally less picky with the RNY sheeple. * Note that in CA, you can avoid the 6 month diet or 10% weight loss requirement by immediately appealing to the CA Dept. of Managed Health Care. But if you don't fast track that appeal, it will take 4-6 months anyway. I can help you get in contact with the right people at the DMHC if you have one of these stupid requirements. * While you are in the approval process for WLS, find yourself a DS surgeon. Get a consult, and pay out of pocket for it. Get a letter written for you by the DS surgeon that explains why the DS is better for YOU than the RNY. This can be because you are SMO, have a family history of stomach cancer, have arthritis or other reasons to need or expect to need in the future to take NSAIDs, have the need to be on anticoagulants, have a Nissan wrap, or some other PERSONALIZED reason. You may as well get the psych consult out of the way at the same time. * In the meantime, you will be writing your request for the DS for after you are approved for the RNY. You are gathering the papers that show the SUPERIORITY of the DS to attach to your request. * When you get approved for the RNY, you IMMEDIATELY submit your request for the DS instead, including the well-written letter with your reasons why you want the DS, copies of the scientific literature supporting your reasons, and the letter from the DS surgeon recommending it for you in particular. * The insurance company will take every day of the permitted period to deny you. You will try not to take this personally (HAH!). * You will take their denial, and IMMEDIATE submit a request for a second level review. It will essentially be a copy of the first well written letter, with a request for reconsideration. You will maintain your calm, because there is NOTHING personal about this -- it is business (note that I was completely unable to follow this rule and wasted a lot of unnecessary emotion on this part of the process). * The insurance company will take every day of the permitted period to deny you again. * What happens next depends on your type of insurance, and possibly which state you live in. If your plan is self-funded, the company ultimately has the power to overrule the insurance company, and your route of appeal is through the company's HR dept. If your insurance is fully funded, then you likely have the right to external medical review -- that information should be provided to you in your second level denial. * In CA, that review is generally to the CA Dept. of Managed Health Care, which is VERY pro-DS. The process takes about 30-60 days (I believe it's 30 days from when the DMHC gets a copy of your medical records and appeals from your insurance company), and at the end, they overturn the denial in most cases. The process may vary in other cases, but the important thing is that EXTERNAL medical people will review the case. More and more, the external medical reviewers are overturning the denials. Don't let the insurance companies dictate how you are going to live the rest of your life.

I have federal Schaller Anderson and was denied for the exact same reason (word for word).  I won my appeal if you would like to see the letter.   Lyns

I would LOVE to see the letter.  Was this for the Sleeve or RNY? Thanks for your help, MJ