Revision to DS - Insurance Exclusion?
I am 8 yrs post op and have regained 60-70 pounds in the last four years due to an enlarged stoma and pouch.
I have been toying with the idea of looking into a revision to a DS to correct the issues. On Friday, I saw a NYC doc (thanks for the recommendation Michelle F) that said that I definately was a candidate for a DS revision and that he would do it --
Finally, I allowed myself some positive thoughts about going forward -- only to find out today that my employer's medical policy has a bariatric surgery exclusion! Self--paying would be about $35K -- definately out of my budget!!!
Anybody successfully battle an exclusion?
I have been toying with the idea of looking into a revision to a DS to correct the issues. On Friday, I saw a NYC doc (thanks for the recommendation Michelle F) that said that I definately was a candidate for a DS revision and that he would do it --
Finally, I allowed myself some positive thoughts about going forward -- only to find out today that my employer's medical policy has a bariatric surgery exclusion! Self--paying would be about $35K -- definately out of my budget!!!
Anybody successfully battle an exclusion?
Nannette
Lap RNY 6/16/03
Revise to DS 8/15/11
Unfortunately I haven't seen anyone succeed when there is an exclusion. Believe me I'd get a revision if I didn't have an exclusion. While you can appeal a denial I don't think there is anything that can be done for an exclusion. I may be wrong and hopefully someone will prove me wrong, I'd love it.
Look into going out of the country if you are going to end up being self-pay. Gagner is in Canada. But his fee plus hospital sounds like it is around what you would pay here in the US. Check Mexico (Dr. Ungson) or Brazil (Dr. Balatzar -- He trained Ungson) I have heard all 3 do RNY to DS surgeries with success.
http://www.obesityhelp.com/forums/revision/4382488/i-am-now- a-self-pay-patient-where-the-h-do-I-go/
Do your due-diligence to yourself & RESEARCH!!!!! Oh, and post your research so other people may benefit. That way we can ALL Pay It Foward!!!!!
That stinks about your exclusion, but YOU ARE NOT ALONE!!!! Me and another gal are in our appeals process & will self-pay if we lose our appeals.
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Hi! Not sure if it's the same thing or not, but my insurance had what I considered an exclusion to weight loss surgery. It said basically the "Weight loss surgery is not covered by this plan, it is considered an elective surgery". BUT, when you continued reading further down into the section (this was in the insurance handbook they give you).......it said that anything not covered, may be covered IF it was considered medically necessary. Bingo!! That's all I needed. From then on, every time I went to the doctor, I made sure that he documented my problems that were either caused by, or exacerbated by, my weight. Then I finally asked for a referral to a local WLS program. When the insurance reviewed my chart, they must have found what they were looking for because I was approved immediately! Good luck and make sure your doctor is actually documenting your complaints and problems.
Roni in PA :)
"Those hairline cracks running through me are stronger than your wholeness. Every stitch on me represents an obstacle I've overcome."
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