Ahhh...The Carousel That is Insurance. All About Approvals?

Hello! I would like to hear from anyone that tried to have their insurance cover the sleeve. Or just anyone who knows all about insurance

I'm considering the sleeve. And as ALL of you know, most insurances won't cover it because it's "experimental". I know some insurances have started to, but that's not the point here. You see, I have BCBS of TN and I was kicked off my mom's plan back in December when I turned 19; HOWEVER, we are cobraing my insurance so I DO have health insurance just the same as I did before. 

I meet with the surgeon on the 13th and I don't know what surgery we will decide on but the only two my insurance has already approved me for are: Lap-Band and RNY. So if we decide on the Sleeve or the DS what will happen next? I would like to know from a Sleeve point of view because that's what I'm inclined to choose; however, I welcome any response. Please.

So let's say the surgeon and I decide on the Gastric Sleeve which my insurance does not cover. I've seen lots of posts about appeals and I'm not sure if the next step would be to appeal but I'm interested in knowing how the process works. What happens when you decide to go for the Sleeve but insurance doesn't cover it? Where do you go from there? Please be as detailed as possible as I am in completely foreign territory.

I've posted this here as well as on the VSG board...just trying to get any help I can here. Also, if anyone knows of any websites that explains the process in layman's terms (sp?), please share.

Thanks a bunch! 

xoxo,
Bekki

Also, I would just like to add that my mother is convinced that the appeal process is quick. From what little I understand about it, it seems like it can take a LONG time. It doesn't appear to be a one time thing. Can you continue appealing if they continue denying? How long can you continue appealing until they've had enough? Ahh! I'm so lost!

First things first... with your BMI I really hope you look at DS.  Your BMI is 63.6, I don't know how tall you are so just for the sake of examples...

Let's say you are an average 5'6", that would put you at 395#.  The sleeve will stistically give you an 80% EWL, so you should lose around 245# to be a normal BMI.  80% of 245 is 196# weight loss.  That leaves you with a BMI of 32.1.  That's still obese.  DS is going to be a more reasonable option for you at least getting you out of the obese range.  You should look at this as a once in a lifetime opportunity, IOW, get the right surgery the first time.

As for appeals the first thing you need to do is be denied for the surgery type you want.  You jump through all the following hoops:

POLICY

• Bariatric surgery, using a laparoscopic or open procedure, for the treatment of morbid obesity is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

• Sleeve gastrectomy, on its own, or in combination with malabsorptive procedures, for the treatment of morbid obesity is considered investigational.

• Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.

MEDICAL APPROPRIATENESS

• Bariatric surgery, for the treatment of morbidly obese individuals 18 years or older, is considered medically appropriate if ANY ONE of the following criteria are met:

  • An individual who has had a prior bariatric surgical procedure and is requesting / requiring a revision, alteration or reversal must have a related medical or surgical complication of that procedure that is documented by the physician

  • ALL of the following:

    • The Pre-Bariatric Surgery Evaluation Tool must be completed and submitted with the request for authorization

    • The attending physician must submit evidence that the attempt at conservative management was within two (2) years prior to the planned surgery

    • The attending physician must submit records that the individual has successfully lost 10% of initial body weight prior to the date that the authorization is requested

    • The attending physician must be someone other than the operating surgeon and his/her associates

    • The individual has a diagnosis of morbid obesity that has persisted for at least five (5) years, and is defined as either:

      • Class 3 obesity with a BMI greater than or equal to 40 kg/m2

      • Class 2 obesity with a BMI 35 to 39.9 kg/m2 in conjunction with any of the following obesity-related comorbidities that will reduce the individual’s life expectancy:

        • Coronary artery disease

        • Type 2 diabetes mellitus

        • Obstructive sleep apnea

        • Three or more of the following cardiac risk factors:

          • Hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic)

          • High density lipoprotein (HDL) less than 40 mg/dL

          • Low density lipoprotein (LDL) greater than 100 mg/dL

          • Impaired glucose tolerance (2-hour blood glucose greater than 140 mg/dL on an oral glucose tolerance test)

          • Family history of early cardiovascular disease in first degree relative (myocardial infarction at fifty-five years of age or younger in a male relative or at sixty-five years of age or younger in a female relative)

    • Psychiatrist/Psychologist must submit ALL of the following:

      • Documentation of the individual’s willingness to comply with both the pre and postoperative treatment plans

      • Interview/evaluation results

      • Minnesota Multiphasic Personality Inventory (MMPI 2)

      • The Eating Disorder Inventory (EDI-2) or the Eating Attitudes Test (EAT-26)

NOTE: If any of the above (Interview/evaluation, MMPI 2, EDI-2 or EAT-26) provides a suggestion of cognitive slippage or psychosis, a projective test (e.g., Thematic Apperception Test (TAT) or the Rorschach test) is required.

After you do the above you submit to insurance.  When they decline you see why they declined you.  If it is due to the sleeve/DS being investigational then you need to demonstrate why you cannot have a band or bypass.

According to this link:

www.bcbst.com/MPManual/Bariatric_Surgery_for_Morbid_Obesity. htm#Bariatric_AI

It does not show which procedures are covered.  It merely lists what surgeries are done, not what they will pay for.

Typically you appeal 1-3x and then you set up a peer to peer review.  If that fails, the doc at the Ins Co typically has the last word.

I wouldn't be wasting any amount of time, this could take awhile.

They will most likely deny a sleeve as experimental.


http://www.bcbst.com/MPManual/Bariatric_Surgery_for_Morbid_O besity.htm

Based on the following:

Sleeve gastrectomy, on its own, or in combination with malabsorptive procedures, for the treatment of morbid obesity is considered investigational.

The length of time for a pre-service appeal can vary dependent upon state law and Dept of Labor requirements.