Filling for approval

When I talked to a program coordinator she said that they won't submit for approval until I have meet the IBX guidlines for a 3 month supervised diet and that they can only sumitt 3 times and after that you are out of luck 

Has anyone else heard this?  I kind of want to know if IBX will approve a VSG because if they won't and I have to go self pay I don't want to outlay the $$ for the supervised diet

TIA 

Based on IBX website, VSG is not covered based on the medical policy.

http://medpolicy.ibx.com/policies/mpi.nsf/88c0c50066c9d05985 2574d300564913/85256aa800623d7a8525761200612cd3!OpenDocument
 

 

I read though the IBX website and it does say VSG is covered. 
Good Luck

Here is the criteria for Commercial products and VSG is not listed.  VBG is listed, but not VSG

COMMERCIAL (NON-MEDICARE) PRODUCTS

ADULT CRITERIA
Bariatric surgery for morbid obesity in an adult is considered medically necessary and, therefore, covered when all of the following criteria are met:

• The individual has either one of the following:
  • A Body Mass Index (BMI) greater than or equal to 40 (Refer to Attachment A to review the BMI Chart.)
  • A BMI between 35 and 40 in conjunction with one or more comorbidities related to obesity (eg, hypertension, coronary artery disease, Type 2 Diabetes Mellitus, obstructive sleep apnea. Refer to the coding table for diagnoses codes that represent a BMI of 35 or greater.)
• The individual meets all of the following:
  • Is 18 years of age or older
  • Has documentation of a failed history of medical weight loss
  • Is not currently pregnant and/or breast feeding and has agreed to avoid pregnancy for at least one year postoperatively
  • Has participated in preoperative care that includes all of the components noted below. Preoperative surgical care can be directed and provided by the member's physician or through a multi-disciplinary surgical preparatory regimen, which is typically based at facilities that are either certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center (program standards and requirements effective February 15, 2006) or by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE) (program standards and requirements effective February 15, 2006):
    • A thorough medical history and physical examination
    • Consultation and instruction by an eligible health care provider on low calorie diets and an exercise program based on the individual's capability
    • An evaluation by a licensed mental health care professional that specifically evaluates: any mental health or substance abuse condition; the emotional readiness and ability of the individual to make and sustain lifestyle changes; and the adequacy of their support system
       
• The individual is scheduled for one of the following operations:
  • Vertical-banded gastroplasty (laparoscopic [43659] or open [43842])
  • Adjustable gastric banding (laparoscopic [43770] or open [43843])
  • Roux-en-Y Gastric bypass with long limb (distal) (greater than 150 cm) (laparoscopic [43645] or open [43847])
  • Roux-en-Y Gastric bypass with short limb (proximal) (150 cm or less) (laparoscopic [43644] or open [43846])
  • Biliopancreatic diversion (laparoscopic [43645] or open [43847])
  • Biliopancreatic bypass with duodenal switch (laparoscopic [43659] or open [43845])

For individuals who do not meet the medically necessary criteria above (eg, individuals with a BMI less than 35), bariatric surgery is considered not medically necessary and, therefore, not covered because their safety and/or efficacy cannot be established by review of the available published peer-reviewed literature.


They also list:
EXPERIMENTAL/INVESTIGATIONAL
For surgical intervention of morbid obesity or morbid obesity and Type II DM in adults,the following procedures are considered experimental/investigational and, therefore, not covered because the safety and/or efficacy of these procedures cannot be established by review of the available published peer-reviewed literature:

• Gastric balloon (43999)
• Malabsorption (Regulatory metabolic) surgeries (eg, jejunoileal bypass, jejunocolic bypass - laparoscopic [44238], open [44799])
• Mini-gastric bypass (laparoscopic [43659], open [43999])
• Sleeve Gastrectomy [43659], open [43999])
• Two-staged procedure(s) (laparoscopic [43659], open [43999])

Thanks - anyone heard of the 3 stikes and you are out?  you can only file 3 times and if you are not approve you are done