Challenging Insurance for Coverage/Approval on Uncovered Procedure?

Hello Everyone!

I had a general question and wanted to see if anyone had challenged their insurance who covered other gastric surgical procedures, but not the sleeve specifically?

I have good reasoning, and I think my doctor will agree that none of the covered services are a good fit for me. My insurance covers the traditional gastric bypass, the band, and the old vertical banded gastroplasty (which I don't think is even done anymore to be perfectly honest). I want to challenge them and have my doctor back me to see if they will give and cover the sleeve with a letter of recommendation from him and why he thinks nothing else is good for me.

Anyone else have similar experiences?

Do you have a medical reason why you cannot have RNY? Has your doctor confirmed that condition and is he willing to write a letter for you?

Not medical, more lifestyle, as I play a physically demanding full contact sport (roller derby) and the way I exercise, that would pretty much be a career ender for me. I can't afford to be deficient on vitamins and have osteoporosis. I've seen fully healthy girls break ankles, wrists, etc, and I don't want to put myself in the kind of position where I'm vulnerable, because this sport is my life and my support network. It's like an non-college sorority almost.

At this point, it's either challenge or do without 100%.

If you take your supplements and watch your lab work, you will never be deficient in anything with RNY. People who take care of themselves don't have deficiencies. Lots of people with the sleeve ignore supplements because they think they're OK, and end up with all sorts of deficiencies.

No one, surgery or not, is immune to vitamin deficiencies and osteoporosis. A lot of us end up much healthier than your average person, because we pay attention and increase or decrease supplements as needed.

Since they are covering other WLS surgery procedures, there is hope - it depends upon how aggressive you want to be in going through the appeals process, going beyond the insurance company themselves and to the state regulators if necessary. If they did not cover any WLS, then there is little hope.

The nutritional aspect is good, trying to minimize the deficiencies typical of the bypass. Another aspect to pile onto it is in medication flexibility - the VSG, and related DS, are much friendlier to many medications such as NSAID pain relievers which are big no-no's with the bypass (I know several who have used that reasoning to get such insurance decisions overturned at the state regulator level.) As the VSG is normally covered by Medicare these days, the insurance companies can no longer use the "investigational/experimental" dodge that they used to use.

Good luck,

Thank you SO much for this info!

Also, I have CoventryCares which is a medicaid program (I'm low income but working so I guess that's why I qualify for it?) and it just seems like they haven't updated the procedures in a while. I know the regular medicaid programs cover the sleeve so it's kinda weird this plan does not.

start by talking to a supervisor at the insurance company I spoke to 4 people and got 4 diffrent answers till I ask for the supervisor , and get there name and ask for your answer in writing

Not too many years ago, most insurance policies would not cover the sleeve. It was a new procedure, with a very small track record compared to RNY and the band. As the procedure has gotten much more common, most insurance companies dropped the prohibition, but as you have seen, some still have not. Canada, I believe, still does almost all RNY, and you need special exemptions to get a sleeve.

On the other hand, many are now dropping coverage for the band, because as its track record grows, it has worse results, and costs insurance companies a lot more in the long run.

If it were me, and the only choice was RNY, I wouldn't hesitate. I guarantee, that, after surgery, you will never even know what surgery you had, without looking at pictures of your innards. We eat the same, feel the same, look the same. There is very, very little difference. If you think you won't have to be as rigorous with vitamins and labs after VSG, you should rethink WLS altogether. You'll have to work just as hard keeping labs in line. The ASMBS recommendations for supplements after RNY and VSG are exactly the same.

A fair number of people revise to RNY from VSG, mostly because of severe reflux. Besides the acid, ask them if they can tell the difference between the two procedures. They can't.

I know for sure the band is out of the question for sure for me, 100%, and it scares me slightly.

You have given me more to think about though, that's for sure. I actually go speak to my doctor next week and I'm just trying to gather as much info as possible before hand. My BMI is between 35 and 40 and I have two co-moralities so I qualify, but I've always been told my BMI is too low for the RNY and it's more successful in people with a BMI range of 55+.