Question:
I have been denied after first letter because they say the procedure is malabsorptive
BCBS of Il denied my first letter stating "We have reviewed the information submitted and determined no benefits are available for Gastric Restrictive Procedure (CPT 43847). The medical effciency of Malabsorptive procedures as compared to restrictive procedures has not been established through appropriate randomized clinical trials and is not a covered benefit." I had been told earlier that the roux en y gastric bypass is covered as long as it was medicall necessary and if the medical necessity letter was sent to them by my PCP. I plan to appeal, but I thought the roux en y was restrictive and malabsorptive... Has anyone else gone through this? Any advice? — Lea H. (posted on September 9, 2003)
September 9, 2003
I was under the impression that the roux en y was one of the few procesured
that is not malabsorbtive. I went to a seminar, and that was one of the
issues they stressed when going over this procedure, and several others. I
would talk to your surgeon, and a few other doctors, and get their view
points, and if you can, have them write their views, and submit those to
the insurance. I haven't had any problems with vitamin deficiency or
anything, you just have to take vitamins. :-) good luck!
— Katrina K.
September 9, 2003
Um, all forms of gastric bypass are malabsorptive. The only *solely*
restrictive operations are the Adjustable Gastric Band and the Vertical
Banded Gastroplasty.
Descriptions of the surgeries can be found here on Obesity Help:
http://www.obesityhelp.com/morbidobesity/types.phtml
— Maria N.
September 9, 2003
I am not sure where you work or if you have a friend in a doctors office,
but take a look at the CPT book for 2003. It lists all the procedure codes
and their descriptions for billing purposes. It may make it a bit more
clear for you. If you can't get a hold of one, let me know I will be glad
to fax you the page you need.
— Angela T.
September 9, 2003
There's very little malabsorption in a proximal RNY, but distal is pretty
severe. Not sure which type you're going for. In case you do lose your job
or switch to one with no or delayed insurance, there is COBRA, which lets
you continue your insurance for 17(?) months, paying the premiums yourself.
Not great but better than nothing! In case you want to research the DS,
which is malabsorptive but much safer than distal RNY, go to
duodenalswitch.com. Good luck with your appeal!
— Chris T.
September 9, 2003
When I typed in that CPT on Yahoo It states its for the
"Duenenal" Switch not the RNY. BCBS as a whole (tho if you
appeal you can win) does NOT cover the DS proceedure.
— star .
September 9, 2003
Have it submitted under the 43846 code and it should go through right away.
The 47 code has a very strange description. I know someone who just had
surgery with the 46 code and has BCBS of IL and got it approved in one day
and she was only a 43 BMI but did have sleep apnea. Just have your surgeon
write a new letter and indicate that they used the wrong code. I can tell
you that BCBS of WI will not approve the 47 code either as they say it is
experimental. If you need longer than a 100cm bypass that the 46 code
allows, then nicely ask your surgeon to be creative and indicate that you
were "bypassed an amount approriate for your BMI". One just
never knows when they might request a copy of the surgical report. Don't
need to get a huge bill at some time in the future.
— zoedogcbr
September 9, 2003
The term "distal" RNY is very subjective. If one is referring to
a 150 cm bypass then it is very safe and moderately malabsorptive. A long
limb or very distal RNY is usually anywhere from 300-500 cm bypassed, which
is very risky. You end up with a very short common channel like a DS but
the difference is that the DS is designed differently so it can be safely
paired up with the really long bypass.
<p>To those who think that an RNY is not malabsorptive please do more
research before proceding with surgery. It is critical that you understand
what is being done to you and what the long term implications are!
— zoedogcbr
September 9, 2003
I have BCBS of IL PPO and was approved for open RNY and I was deemed to
need it because it was medically necessary for me. Does your surgeon do RNY
procedures and are your willing to go that route? And yes the RNY is
malabsorptive. Good luck with your appeal.
— ChristineB
September 11, 2003
Thanks to all that responded. I know that the procedure is restrictive and
malabsorptive... see above... but I'm not sure on the length of the limb...
I am planning to have the open roux en y gastric bypass procedure. I
welcome any suggestions or insights. Thanks again! God Bless :)
— Lea H.
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