DS doctors withthe best staff who know insurance inside out!

  I'm seeking a revision from RNY to DS but I'm worried about my insurance.  I want to go with the best doctor as well as the best office that will support my journey.  Therefore......I'd really be interested in hearing from you guys which Dr's office you believe was the best in going to bat for you to fight insurance denials.  Or which office you think prepared the best prior to submitting your information for insurance in order to lessen the chance of a denial.

My insurance (BCBS MA) covers weightloss surgery but will only cover DS in specific situations  This is exactly what it says:

"We cover the following surigal procedure For Medicare HMO, Medicare PPO Blus and Blue Medicare PFFS Plus RX members only in accordance with centers fo Medicare and Medicaid services : Biliopancreatic diversion with duodenal switch-open and laprascopic"
 
Further down it states-The following will reject as non-covered leaving no patient balance as these procedures do not meet our medical technology assessment guidelines:
 
CPT 43845 (covered for Medicare HMOB, Medicare PPO Blue and Blue Medicare PFFS Plus Rx only)
 
This is odd to me.  How does it not meet the guideline yet  they cover it for a certain sector?  Is this a loophole that can be used?

Please help.  I'm ready to fight!

 Medicare only requires that a patient have a BMI > or = to 35 with comorbid conditions to qualify for WLS. They do not specify which surgery. If you meet this criteria you can have whichever WLS they cover. Your insurance BCBC MA may have their only criteria for the DS. Here's the link to Medicare's website: https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?from2=viewd ecisionmemo.asp&id=160&

I know that in my case, my insurance Health Net, would only cover the DS for patients with a BMI > 50 (my bmi is only 47) they denied me the DS. I appealed twice and then filed for IMR with the DMHC (a CA state agency that oversees HMOs). Health Net's denial was overturned and I was approved for the DS. Do you know what your external review options are if you are denied by your insurance and you exhaust all their internal appeals?

I don't know what to tell you specifically since I'm not a revision, but I just wanted to suggest that maybe you could start by getting your insurance companies specific criteria for the DS and go from there. If the only thing they state about DS coverage is Medicare's guidelines then I would think you would qualify for DS if your BMI is > 35 with comorbidities. It may be easier to get a revision or it may not. I don't think you'll really know until your surgeon's office submits. Many insurance companies will deny the first time because they can. Have you posted this question on the DS board. Maybe someone there could recommend a DS surgeon they used who is good with handing all the insurance BS. Best of luck to you and never give up. Sorry if this post rambled, I hope you'll find something useful in it. Neely

The thing with BCBS of MA is they do NOT cover the DS for their members UNLESS they are members via Medicare. It's absurd.