VSG code for United Healthcare Choice Plus POS

Has anyone heard if United Healthcare will adopt the VSG code that is suppose to be available in January?  I will be done my 6 month doctor monitored visits in January and am hoping that when the doctor submits my request for the VSG it will be approved.  Anyone been approved for the VSG that has this insurance??

Hi Nicole,

I just submitted an appeal to UHC for VSG.  The way their medical policy for bariatric surgery is written, they would have to cover VSG if it gets a CPT code.  That is because when the AMA grants a CPT code for a procedure, it is only given when, "generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations. and, "In developing new and revised regular CPT codes the Advisory Committees and the Editorial Panel require: ...that the clinical efficacy of the service/procedure is well established and documented in U.S. peer review literature", (among other requirements).  Right now the UHC policy has VSG as "unproven" but the last review date was in 2007.  If VSG gets a CPT code, it sure can't be "unproven" anymore!

I posted my appeal on another website.  http://verticalsleevetalk.com/insurance-financing/1496-my-ap peal-draft-w-references.html Maybe there is some content there to help you.  I should know whether this first appeal goes through in 15 days.  But, there are several levels of appeal so I'm not giving up on this one, and I don't want to wait for the new CPT code.  It *might* be January 2010... the AMA committee is meeting mid-October, and if VSG is reviewed then it could still be months before it gets a CPT code; and, it may not be until February or later that it gets reviewed.

Good luck!

Luanne

Hi,
I am in the process of preparing for a denial...I have bcbsnj and they have already told me that they do not cover VSG.  Another member gave me the CPT code of 43659.  Has anyone tried this #? 

I don't want to wait until it is covered either..too far in the future.  Although the thought of going to Mexico to have a surgery that I could have in a top notch local hospital makes me crazy!

Lunanne..love your appeal letter and research! thanks!
Kris

Hi Kris,

I did call my insurance w/that CPT code and was assured that they covered it.  Later, after meeting w/the surgeon, I talked w/her insurance person and she explained that there is no CPT code for VSG - that 43569 code is as close as they can get to describing it.  They have to submit both a CPT code and a description of the surgical procedure that will take place.  Then, when the insurance company reads the description, they deny it.  This was, in fact, what happened - I called w/the CPT code of 43569, they said they covered, surgeon submitted preauthorization, insurance denied it. 

It really helped me understand the insurance company's position when I was able to locate their medical policy and read the bariatric surgery section.  Understanding where they were coming from helped me frame my appeal.    I have a .pdf of the UHC medical policy, but haven't tried to find the BCBS one.  My guess their rejection of VSG is based on the same information as what UHC used - and that, it out of date. 

If you want any help finding information or drafting your appeal - let me know.  I love these kinds of fights.  :-)

Cheers,

Luanne