Question:
How Do I Get Around This Obstacle?

I just heard from my insurance company - now they have changed their mind. They are saying my request is denied because I want to go out of network for the DS but they want me to stay in network which means RNY. Nothing against any one procedure, but I came to this decision on my own. I have out of network benefits, excluding morbid obesity out of network. This means if I want morbid obesity surgery, I need to stay in network. I know many people here have gotten around exclusions. How did you do it. What do I have to say so they will let me go out of network. I tried the inadequate coverage deal, but they said they don't care about the procedure type, so they won't let me go out of network. HOW DO I GET AROUND THIS OBSTACLE???    — Melissa T. (posted on October 18, 2001)

October 18, 2001
The only way to get around this is to appeal with clinical documentation supporting that RNY would be harmful, ineffective, or medically inapproptiate for you and that the DS is the only wls approach available to you. That would be one "tall order". Why not have the RNY? It's safe, effective and results in a greater weight loss.
   — [Anonymous]

October 18, 2001
Statistically, the DS has greater long term weight loss due to the fact that it is a distal procedure and the malabsorptive component assists with keeping the weight off long term. A distal RNY would give equivalent weight loss, but most people don't get distal RNYs. Also, you retain your pylorus valve with the DS, so you have a smaller, but normally functioning stomach so you don't need your stoma dilated, etc. Is your policy a PPO or a HMO and did you say they specifically exclude out of network weight loss surgery ?? Unfortunately, if it's worded that way, I don't know how you would get around it. What insurance company do you have ? Is there anyone that is out of state, but in-network that you could use ? I'm in Denver, CO and I will be having surgery with Dr Keshishian in Delano, CA
   — Anita N.

October 18, 2001
Don't listen to the nay-sayer. I have decided on the DS too and I'm in Florida, so any surgeon for me is going to be out of network. I am getting my psych eval soon (that is the last step) and then I'm going to apply to the insurance company. If they deny me then I guess I'm just going to have to take out a loan (after a creative appeal or two). Interest rates are good at present. I know it's a lot of money to pay out of pocket, but I think it's worth not having to worry about not drinking while you eat or throwing up if you eat too fast or dumping on sugar. Distal is distal is distal... neither procedure is "superior" it's just about what you demand of your quality of life post-op. Best of Luck!
   — [Anonymous]

October 19, 2001
Unfortunately the only "research" that truly counts is insurer's research. Going out and getting other insurance isn't as easy as it sounds. The first anony one might be on the right track. RNY is the right approach for some patients; but DS is the best approach for others. Speak to the surgeon, explain the denial to him and ask him to provide a written statement supporting the medical reasons for DS...why it is the better approach. You might be denied on the next level; but, do go to the next level. Exhaust all your appeal rights. But, remember that insurers won't give any weight to "I want to avoid nausea...metabolic deficiency" arguments. "What if's" don't work. You have to base your appeal for the DS on current, documented medical issues. Good luck.
   — [Anonymous]