Insurance Clarification / CPT Code Regarding Stomaphyx ?

I have just been denied the stomaphyx procedure by my insurance.  They are saying it was denied because it is an investigational procedure.  The person I spoke with referred to the fact that the surgeon's office used a miscellaneous CPT (current procedural terminology) code for the request for precertification.  I am wondering if anyone has been approved through insurance for the stomaphyx and if they know what CPT code was used to request the precertification/approval?   I am wondering if a CPT code even exists for it yet, but the procedure would still have to fall under something for whoever has had it done.  I now have to appeal and any help/insight would be appreciated.  Trying to get ahold of someone at Endogastric Solutions has not been easy.  

They do not have a code for this procedure yet, they are using a general code.  No one that I know of has been approved yet, all insurance says it is investigational.  A friend of mine just got her denial also, the doctor even said no one has yet had their insurance pay for the procedure.  I am having a complete revision done and I think I want the stomaphyx for the stoma and the pouch.  They need to make me distal since I hardly had any bowel removed.  Do you need to have a complete revison or just the stoma and pouch,  There is something that some doctors are doing that used stitches instead of the staples.  I had that done in Boston and it worked for about 6 months. Hope this information helps some.  If you have the total revision they will pay.

I can't help you with your request....but my insurer (Blue Cross Blue Shield of Arizona) specifically DENIES StomaphyX by name in their policy sheet.   Other approved revisions require a great deal of documentation (BMI over 35, demostration of failed WLS etc)     ACK!  It's amazing that they actually pay for ANYTHING AT ALL.   Between what I pay and my company pays for this policy for a family of 3....it's more than $20,000 a year!   You'd think they could be a bit more generous since, on average, I doubt if my family uses $2000 of professional services covered by the policy annually. Just my two cents worth since I've spent the last hour reading from cover to cover my policy to see how I can get plastic surgery partially covered through them!   (It doesn't look likely there either.) Lorri

I am like you, wondering if there is a cpt code for this procedure. If we have to use an unlisted code, how will we ever get an approval from the insurance companies.