Question:
Why won't insurance cover Fobi procedure?

I've asked this question several times and in several different ways, but the responses I've received (although welcomed) haven't given me a clue as to why this particular procedure is not covered. It essentially is the Open RNY procedure with a few extras. The stomach is transected vertically and a silastic band is placed at the stoma, you have a gastrostomy with a gastrostomy site marker put in the unused portion of the transected stomach (this is in case damage occurs to the pouch or if there is too much weight loss, this marker (tube) can be located and you can receive meds or feedings directly into the unused portion of the stomach). I have no idea what the exact cost of a Open RNY will be, but my surgeon has indicated that my insurance will probably approve the Open RNY, but if I want the Fobi part of the procedure it will cost me out of pocket $1800.-$3200.00. Can anyone out there tell me why this is? This procedure is not experimental, it has been around for many years. This procedure is being covered, at least here in Georgia, by Medicare and Medicaid. Why can't I request and receive the procedure my doctor feels will be better for me and my long term weight loss management when I am being insured through preminums paid at my husband's place of employment? IF ANYONE CAN ANSWER THESE QUESTIONS PLEASE LET ME KNOW AT [email protected]. Thanks, Jo-Dee    — tinyjo (posted on May 29, 2002)

May 29, 2002
Victoria Bowen had this procedure done. She is very knowledgeable and could probably answer your questions.
   — [Deactivated Member]

May 29, 2002
I had this procedure done and it was totally covered by my insurance. Perhaps your insurance company doesn't cover it because it is more costly.
   — Helen C.

May 29, 2002
"This procedure is not experimental, it has been around for many years. "--------not true...the only two WLS that are not experimental are the Open RNY and the VBG ......a long length of time being performed doesn't take it out of the experimental category ........my insurance company specifically lists that it doesn't cover the Fobi, the micropouch, the DS, or the adj lap banding because they are all experiemental...it will only cover the RNY and VBG becasue the National Institute of Health endorsed them
   — Jeff B.

May 29, 2002
As great as it is to have insurance, it can still be a pain in the behind. Insurance companies determine which procedures to cover based on the cost of the procedure. Cost isn't the only factor, but I would say that it's the most important one involved. If they have a choice of approving Open RNY at a cost of $5000 or Fobi at a cost of $9000, they'll always select the lowest. Generally, if there's a good reason to have the more expensive procedure, their decision can be appealed and your doctor can help you with that. Also, different insurance carriers have specific procedures that are excluded, it could be again, cost related, or it might be related to the effectiveness of the procedure or they may consider it experimental; it just varies by insurance carrier. What has your insurance carrier told you? Have they given you a detailed explanation as to why the procdure isn't covered? Has your doctor provided information to show why the Fobi would be more beneficial and work better for you than RNY? What kind of insurance do you have?
   — Rosario T.

May 29, 2002
I have a couple thoughts regarding this. Sorry, but I seem to be the skeptical one of the bunch. First of all it sounds like your SURGEON has told you it won't be covered. Have you checked with your insurance? Maybe the surgeon knows that his reimbursement will be small (although the procedure is a covered one) and wants you to essentially pay the contractural difference. Also, if he does the fobi procedure but bills the insurance for the RNY, isn't that insurance fraud? So, basically he will do the Fobi procedure, get paid for the RNY and then also get the extra money from you. Well, like I said, I'm skeptical...Shelley
   — Shelley.