Is it significant when a procedure is assigned a CPT code?
Hi all,
I am preparing to take on BCBS of MN for coverage for a Vertical Sleeve Gastrectomy. I've been reading a lot of published studies and reports on the VSG, so that I can make a case to my insurance company that the VSG should no longer be considered "investigational."
Here's a tidbit I came across - the CMS (Centers for Medicare and Medicaid Services) will publish a CPT code and Relative Value (how much they will pay for the procedure) in November 2009, to be implemented in January 2010.
So.... if there's an established CPT code... does that mean that the VSG will have been accepted as a medically necessary procedure? Or is the development of a CPT code less significant that I'm hoping it is?
Thank you for any input you can offer.
Naomi
I am preparing to take on BCBS of MN for coverage for a Vertical Sleeve Gastrectomy. I've been reading a lot of published studies and reports on the VSG, so that I can make a case to my insurance company that the VSG should no longer be considered "investigational."
Here's a tidbit I came across - the CMS (Centers for Medicare and Medicaid Services) will publish a CPT code and Relative Value (how much they will pay for the procedure) in November 2009, to be implemented in January 2010.
So.... if there's an established CPT code... does that mean that the VSG will have been accepted as a medically necessary procedure? Or is the development of a CPT code less significant that I'm hoping it is?
Thank you for any input you can offer.
Naomi
Hi Naomi,
Do you have bcbs federal? That is what I have. I posted a topic on this forum just a few minutes ago. As far as I 've heard that 43843 can be used for the VSG. It would be great if BCBS and all other insurance companies would recognize that the VSG should not be investigational any longer. Weight loss is comparable with the RNY. It works. It is less evasive, no dumping or throwing up, and is a whole lot cheaper, etc, etc. Any way read my topic. Thanks for this information.
Blessing
babygirlinokc
Do you have bcbs federal? That is what I have. I posted a topic on this forum just a few minutes ago. As far as I 've heard that 43843 can be used for the VSG. It would be great if BCBS and all other insurance companies would recognize that the VSG should not be investigational any longer. Weight loss is comparable with the RNY. It works. It is less evasive, no dumping or throwing up, and is a whole lot cheaper, etc, etc. Any way read my topic. Thanks for this information.
Blessing
babygirlinokc
Virgie Tschirhart
Lap Band - 2008, Sleeve - 2009, RYN - 2017
Started Program Weight July 13, 2017 - 194.2
Before Surgery Weight December 27, 2017 - 185.0
Current Weight - February 2018 - 161.0
Hi Babygirl,
I have BCBS of MN. My policy states that the VSG is investigational... but later it states that for patients with a BMI > 50 AND significant co-morbidities, they may consider the VSG. Neither of those criteria (BMI nor significant co-morbidities) apply to me.
I wish I could afford to self-pay and then see if insurance might pay. I wish you good luck in resolving your case.
Naomi
I have BCBS of MN. My policy states that the VSG is investigational... but later it states that for patients with a BMI > 50 AND significant co-morbidities, they may consider the VSG. Neither of those criteria (BMI nor significant co-morbidities) apply to me.
I wish I could afford to self-pay and then see if insurance might pay. I wish you good luck in resolving your case.
Naomi
You know most Ins. companies follow suit after Medicare and Medicaid changes policies. I would think that it will not be clasiified as investigational since they are assigning a definite code for it. You and I can search and search to see what code some used and it would be different from one person to the next. I was given 43999 by my insurance coordinator (now I even know that is a generic code)
I know they were going to deny that.
So I really really hope they will change this because I WANT the VSG but was getting discouraged and was tip-toe-ing towards the RNY since I know that is going to be covered. So let's pray they do it before 2010 maybe next month would be nice!!
I know they were going to deny that.So I really really hope they will change this because I WANT the VSG but was getting discouraged and was tip-toe-ing towards the RNY since I know that is going to be covered. So let's pray they do it before 2010 maybe next month would be nice!!
Highest weight- 262lbs
Lap band- Aug 2006 - 254lbs.
Lowest w/band 214lbs. .
Gained up to 271 due to the band
Got DS revision April 2010!! Current 145lbs
At 5'8 my goal was 160lbs but I surpassed that with the DS!!!!!!
Lap band- Aug 2006 - 254lbs.
Lowest w/band 214lbs. .
Gained up to 271 due to the band
Got DS revision April 2010!! Current 145lbs
At 5'8 my goal was 160lbs but I surpassed that with the DS!!!!!!
I was also informed by my surgion that a code is going to come out in January 2010, but they don't know if all insurance companies will take it. I wish there was a way to find out. I hate going to the doctor every month for the 6 month of monitiored weight loss attempts and then for someone to tell me "NO". When I call my insurance company to ask if the VSG is covered they simply say it depends on the code and that they normally cover the band and RNY. (My insurance use to be Mamsi, but is not United Health Care). Some of them don't even know what I am talking about when I say Vertical Sleeve. Does anyone else know anything I should be asking?
Hi Naomi,
It is the AMA that assigns CPTs (current procedural terminology). I have seen a rumor, too, that, "maybe in 2010". There is a meeting of editorial panel in mid-October, and it is there where they will act on applications for new CPTs. They meet 3 times a year and the meeting following this one is mid-February 2010. Is it significant? I do believe so, if it happens. I found a description of the criteria for a new CPT code on the AMA web site; I'll paste it below. Does VSG fit this description? I sure hope so! I'm busy writing an appeal to get my insurance to cover VSG because they currently consider it experimental or unproven. They would have a hard time doing that if VSG gets its CPT code! Good luck to you Naomi.
It is the AMA that assigns CPTs (current procedural terminology). I have seen a rumor, too, that, "maybe in 2010". There is a meeting of editorial panel in mid-October, and it is there where they will act on applications for new CPTs. They meet 3 times a year and the meeting following this one is mid-February 2010. Is it significant? I do believe so, if it happens. I found a description of the criteria for a new CPT code on the AMA web site; I'll paste it below. Does VSG fit this description? I sure hope so! I'm busy writing an appeal to get my insurance to cover VSG because they currently consider it experimental or unproven. They would have a hard time doing that if VSG gets its CPT code! Good luck to you Naomi.
Category I CPT Codes
Category I CPT codes describe a procedure or service identified with a five-digit CPT code and descriptor nomenclature. The inclusion of a descriptor and its associated specific five-digit identifying code number in this category of CPT codes is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations.
In developing new and revised regular CPT codes the Advisory Committee and the Editorial Panel requires:
- that the service/procedure receive approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;
- that the service/procedure is performed across the country in multiple locations;
- that many physicians or other health care professionals perform the service/procedure; and
- that the clinical efficacy of the service/procedure has been well established and documented.
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