What do I do?!

I have mixed emotions right now. I was told that my insurance would cover any malabsorptive/restrictive WLS that a doctor deemed necessary.

I got off the phone office staff for the doctor I want to get my DS through, they said I AM covered but ONLY if I get the banding or gastric bypass. That my insurer will only cover those two procedures.

So, I have read up about this happening a lot, but right now my mind is so garbled I have no idea where to go from here.

I told the office assistant that I wanted to go through with having a consultation with the doctor (which is set up for next Thursday (April 28th). 

Does anybody go through Blue Cross Blue Shield Federal? It says in their 2011 information packet that they cover restrictive, malabsorptive or any combination of the two for people who fit their guidelines of candidates for weight loss surgery...

Has this happened to anyone else with my insurance? What do I do? Should I wait to have my consultation with the doctor, and see what he has to say, so when if I inform my insurance of my choice and the doctor backs me up, there is a possibility of persuading them otherwise?

Please help!

The first step is getting in touch with YOUR insurance company and ask them the requirements and what they cover ... THEN GET IT IN WRITING.  

Every policy is different ... even with the same carrier.

And who is your surgeon?

What Tom said.  And what surgeon are you speaking with?

~Becky

I am not an insurance guru, but I would assume that if your insurance says they cover malabsorptive/restrictive or any combination, that they would cover the DS.

Perhaps your surgeon told you it is not covered because they do not do the DS?

If I were in your shoes, I would, if your insurance says they do not do the DS, appeal that clause.  Make sure you find a vetted surgeon on the dsfacts.com list and call him.   Lots of surgeons say that they do the DS and do NOT.

 Ask your insurance if they specifically cover this CPT code.

Biliopancreatic Bypass with Duodenal Switch – (CPT code 43845: gastric restrictive
procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and
ileoileostomy [50 to 100 cm common channel] to limit absorption [biliopancreatic
diversion with duodenal switch])

My surgeon is Myur S. Srikanth of Federal Way, Washington. For the Center for Weight Loss Surgery. (http://www.centerforweightlosssurgery.com/). I actually found him on DSfacts.com.

This image was taken directly from the 2011 service benefit plan PDF file off of http://fepblue.org/

http://i473.photobucket.com/albums/rr98/Kawaii_Kouture/WLS/proof.jpg

Is there any reason they wouldn't obied by their rules set forth in plain black and white of their own brochure? Have I overlooked something? When I went and read on about what they offered for WLS they never said anything further about what kinds they covered, only what needed to be met to be considered eligible for coverage...

so... what the hell?

You're confusing!  "Omaha, AR," Kawaii + Washington state...okay what does page 53 say?


 

Kawaii_Kouture is my user name for photo bucket (kawaii means "Cute" in Japanese). I just resently (4 days ago) moved to Washington state (where my family is) from Omaha, Arkansas (where my in-laws are) ( Omaha is a small town 15 minutes south of the missouri/arkansas border) and haven't updated my info here yet (Thanks for reminding me!)

And here is what page 53 says:

http://i473.photobucket.com/albums/rr98/Kawaii_Kouture/WLS/proof2.jpg

Hope that helped :)

Hmmm...SOMEplace in there, there should be a list of exclusions...like that they don't do the Scopinaro procedure or something.  Anything like that?

Not that I can find. Page 52 (the one that has the bit about what kind of surgeries) has no mention of WLS until the bottom where I cropped and posted it. the rest of that page talks about Voluntary sterilization, Biopsy, Colonoscopys, Circumcision of newborns, and things like Insertion of internal prosthetic devices. So basically a small list of proceedures and how much coverage I would get under my standard option plan. But no other words about WLS.