Codes update

I spoke to my doctors office today, after speaking to my insurance company. Everything is clear as mud now. My insurance company calls stomach stapling a "sleeve procedure" instead of what it actually is. No doctor offers or does stomach stapling, which is the reason for the "unlisted" cpt code of 43659 which is also priced at market value. Have you ever been to a seafood restaurant and the catch of the day has no price but instead says market value? It all depends on what the cost is at the time as to what the restaurant will charge. So sayith the gods that control pricing.

Interesting tidbit, it costs the insurance companies more to pay the surgeon for a by-pass than a sleeve operation. The insurance companies also consider the vertical sleeve as elective while the by-pass and lap band are not elective. Hello??? They are all three WLS how can they be differentiated as one elective and the other two requirements. Blows my mind!!!

Back to my surgeons office. I am told that I can have the by-pass or the lap-band but if I want the sleeve I will have to pay $20,000. They also REFUSED to submit any paperwork to the insurance company stating medical necessity, which the insurance company will consider and present before a revue board. After some digging I find this wonderful site that lists all the CPT Codes and what Medicaid will pay out on. I am fighting my insurance company and my surgeons office over $1,285, yet they want to tell me that I have to pay $20,000 to have the procedure. Fraud much???

This is not over!! More to continue, will update as soon as I can.

Can you go for DS & just have the surgeon do the first part (the sleeve) & not do the rest(re route the intestines?) The sleeve only recently became a stand alone procedure, it came from the DS, might be another way to get what you want.

They only do the stand alone procedure. I have been told that several times from my surgeons office.

Get it!!! Ugh, you sound determined like me. Fortunately (for me and all involved) I did not have any complications with my insurance. I had read horror stories of people having issues with insurance. I was SOO ready to fight.....nothing happened. Good luck to you! Keep us posted!

Have you checked out any other surgeons? 

Good luck! I've still got part of my plan being reviewed for coding, wi**** had been done pre-op like you are doing. (I wish there was more communication between Dr's and insurance and common sense)

Have they submitted your paperwork with code 43775?  That code seems to be THE standard code to use for VSG.  I'm not sure why your insurance company would not recognize that code or why your surgeon would bill a different code.  Unlisted codes are for uncommon procedures not ones that already have a code.  I am having the SADI-S procedure.  No code exists for it, so my Dr. will bill 43775 for the sleeve portion and an unlisted code for the malabsorptive part.  

Code 43755 is the code my insurance company won't pay on. That code is specifically for the doctors fee. There are codes for every single line item used during any type of medical procedure. My insurance will pay everything but the doctors fee, on the fee schedule the amount is $1,285. So for that small amount I can not have the sleeve unless I come up with $20,000. It just doesn't sound right to me.

Well it seems your insurance company does not cover VSG.  Having your doctor bill another code is inappropriate since the VSG has an assigned code.  Have you asked the Dr or insurance company if you could pay the surgeon fee out of pocket and have the insurance pick up the anesthesia, hospital, etc?