coding for Stomaphyx procedure

Who exactly is supposed to assign the stomaphyx procedure with a procedure code? I am trying to get my insurance company  (BCBS FEP of GA) to approve my stomaphyx and of course they denied my initial request because they called it investigational! I then appealed with proof that my policy should cover it and a copy of the actual approval letters from the FDA approval so they really can't call it investigational anymore. I have gotten the run around but finally got a hold of someone who talks a little more than she was probably supposed to and she basically admitted that they are getting away with denying the Stomaphyx because there has not been a procedure code created for it. So who exactly is responsible for creating the procedure code?????  I have appealed my precertification denial and my case has been in "Review" for 2 weeks now....they have 30 days to decide an appeal. I will be hiring a lawyer tomorrow morning to get to the bottom of this for me. I'll let all you Stomaphyx hopefulls know how it goes, but if anyone can answer my question about the approval code I would greatly appreciate it!

Dear Mollybeasrsmom,

The surgeon assigns the procedure code. The ICD-9 and CPT codes don't use the word stomaphyx, they use generic codes that just states that it is revision procedure in the gastro area is being used. I work for the medical claims division of a large medical union in the Northeast - and I too was denied approval of the stomphyx procedure.  Here's the problem - it's a new procedure and the insurance companies want proof that it works. I read the message boards and hear there are people who haven't lost weight even after the revisions. The insurance companies want hard evidence that it works more times that it doesn't. The doctors have got to write medical papers showing the numbers, showing how many of their patients had it and how much weight was lost in what period of time. Right now, people are so despreate for the revision that they pay about $10,000 out of their own pockets for the Stomphyx procedure, so why should any of these doctors write an article, or get the insurance companies to pay - they'll get less from the insurance company that they would from you or me - we pay full price to the doctor, we don't get a break for being in-network. Another thing, the insurance companies seem to hinge on each other. My insurance will pay a procedure if Aetna, Oxford or Medicaid pay for it; and those companis probably do the same thing. Realize that you're not alone out there. Many people are being denied the revision procedure - there are very very few insurance companies that will pay for it. As I said before - the doctors are the ones that can make it happen. If they keep bugging the insurance companies - giving medical evidence that it works, showing how it can improve the quality of life for the patient, etc - it will get approved in time. Good luck  Nan C

I believe the AMA is responsible for creating new codes (american medical association), I believe CPT 43999 has been used for Stomaphyx, I haven't heard of many encouraging results.... My policy still calls the DS investigational LOL so I know how much that stinks. Good luck