Carmelita
VSG Insurance Woes
Update: June 27, 2012 ITS OFFICIAL!!!
MEDICARE APPROVED , APPROVES VSG opening the State floodgates to Medi-cal, and Medi-caid covered VSG/ LSG link:
MEDICARE APPROVES VSG
Katikati post link: Medicare Update 7-2012
MEDICARE UPDATE
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Update: Nov. 3rd 2009 ITS OFFICIAL!!!
VSG IS NO LONGER EXPERIMENTAL OR INVESTIGATIONAL
EFFECTIVE January 1, 2010
OFFICIAL CPT CODING......... 43775 VSG CPT
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KNOW the wording to your INSURANCE PLAN for bariatric surgery.
Look ONLINE if you do NOT have the plan IN FRONT OF YOU. Insurance Websites link may be helpful
http://www.obesityhelp.com/forums/insurance/cmsID,8933/mode,content/
IF your policy states LapBand, RNY are covered but VSG is considered INVESTIGATIONAL, EXPERIMENTAL and states these types of procedures are NOT covered
....YOU CAN GET INSURANCE TO COVER VSG!! This is a typical insurance policy. It only means you have to appeal. That's it.
EXCLUSIONS are very difficult cases to WIN. IF the word: EXCLUSION to VSG is in your policy, prepare for major obstacles to win, which could involve hiring an attorney and even then outcome may not be a positive one. Hopefully VSG will gather formal acceptance Jan 1, 2010 and will help remove ALL insurance barriers to VSG not only those based as investigational or experimental, but exclusions as well.
Currently VSG is considered "investigational" or "experimental" by most insurance companies. NUMEROUS denials are overturned by providing a simple statement to appeal based on these 2 conditions to your insurance company.
VSG will NOT be be removed from experimental/investigational until the AMA gives it an OFFICIAL CPT Code .
Every Jan 1st. AMA provides NIH (see below) with new official CPT codes for medical procedures.VSG is expected formal acceptance in 2010 (see below)
Once NIH accepts VSG as officially accepted it clears the way for VSG to be approved & paid thru Medi-care and Medi-caid (federal and state medical insurers).
Once federal and state level insured programs accept VSG as formally accepted WLS procedure, ALL insurance companies are MANDATED to follow NIH guidelines and formally accept VSG as an alternative WLS. Currently to be denied on the basis of "investigational" or "experimental" is distressing, but standard insurance protocol.
Currently many insurance companies are unofficially CPT coding VSG to 43659. If you do NOT know what your surgeon's office coded for VSG FIND OUT!! Many times a denial can be due to a wrongly submitted CPT code!!
Per my surgeon more and more insurance companies are approving VSG as it comes out of its "investigational" category. VSG is still relatively new procedure for WL, altho used for other medical conditions in past. First partial-gastrectomy being done like in 1881! VSG as a weight loss surgery has almost 5 year studies breaking through now. Per protocol 12 US VSG surgeons report their findings on VSG to ASMBS ( American Society for Metabolic and Bariatric Surgery).
ASBS (American Society of Bariatric Surgeons) also submit their data on VSG to ASMBS
ASMBS THEN petitions the AMA for an OFFICIAL CPT CODE. The deadline for CPT petition is in November. In January the AMA releases all new OFFICIALLY ACCEPTED
CPT Codes for medical proceedures.
http://www.asbs.org/
From BariatricTimes 6/09
SLEEVE AND THE INSURANCE INDUSTRY
The American Medical Association (AMA) has not yet authorized the codes for sleeve gastrectomy. Most insurance companies deem the gastric sleeve to be experimental, and so this specific procedure is usually not a covered benefit. There are only two insurance companies that cover the procedure—Blue Cross® and Blue Shield® Federal Employee Plan (FEP) and Oxford Health Insurance® from United Healthcare Network®. Medicaid officially states that sleeve gastrectomy is investigational. There are exceptional cases that can be covered by Medicaid.
There are signs of progress with multiple insurance companies. It should be expected that in 2010 sleeve gastrectomy have its own code and a formal acceptance.
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MY STORY n Im stickin to it!
My co-morbidities included a BMI over 40
Diabetes Type II and hypertension diagnosed Jan 08.
Orthopedic problems- plantar fascities diagnosed May 07 was facing surgery to relieve.
High Triglycerides diagnosed ~15 years ago
I have a family history on both sides with diabetes, hypertension, & atheroclerosis.
ALL OF THESE ISSUES ARE RESOLVED POST VSG. At my 3 months post op appt. my PCP dropped the diagnosis of diabetes II, hypertension, hyperlipidemia, and plantar fascities.
======MY INSURANCE WOES!!======
My surgeon's office submitted (pre)authorization for VSG mid August 08.
I was denied late August on basis VSG considered "investigational"
(this is STANDARD INSURANCE PROTOCOL no worries! )
I appealed by telephone August 29th. 2008
Oct 21, 08 denial overturned and I won VSG 100% coverage on appeal. An Appeals Board member contacted me by phone, as they "supposedly" could not reach me by mail/did not have my current mailing address.
I have BC/BS Anthem Cali
So approx 3 months TOTAL for me! From denial to approval on appeal, supposedly Appeals Board got letters returned; didn't have a current address on me, my surgeon's office never notified me that I was approved. I finally got a call from an Appeals Board Rep tellin me I won on appeal. Got my address and received a letter within a week (see below)...confirming it.
I have since learned:
Pre-authorization request can take up to 7 business days for review.
Appeals take up to 30 business days for review.
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You have the right to CALL YOUR INSURANCE COMPANY EVERYDAY if YOU so choose to get an update on your case whether its, original pre-authorization, or appeal. Even if they say...its pending, in review whatever...call everyday if you want!
You can APPEAL a denial by phone, email, or in writing depending on what your insurance company provides.
TO APPEAL AN INITIAL DENIAL on basis of "investigational, experimental" :
CALL OR WRITE YOUR INSURANCE CO. AS SOON AS YOU KNOW YOU HAVE BEEN DENIED
A SIMPLE STATEMENT is ALL that is NECESSARY....i.e. "I want to APPEAL this decision and Im requesting that a BOARD CERTIFIED BARIATRIC SURGEON be a consultant on the APPEALS & GRIEVANCE Board. Please PUT THIS REQUEST IN MY NOTES UPON SUBMISSION" Get the NAME OF THE PERSON YOU TALKED to if appealing by phone!! They will send you a letter confirming your request to APPEAL within 1-2 weeks. Do NOT send any additional information with your appeal at this level. The Appeals and Grievance board has ALL pertinent information about you when your surgeon submitted for authorization.
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DECISION OVERTURNED..WIN ON APPEAL INSURANCE LETTER
I have BC/BS Anthem PPO of California
Date of inital "investigational" denial - late August.
Date Appeal received by Ins. August 29th. 2008
Date of Reversal of Denial/Approved upon Appeal - Oct. 21, 2008
Here is my letter ver batim! ( the bold is my added comment/s)
Appeal Outcome: Appeal Authorization/ Decision Overturned
Place of Service: Inpatient Hospital
We have completed our review of the appeal for the above referenced services. After careful review of the additional information provided (I appealed by phone! I NEVER sent them anything nor did my surgeon!) , it was determined that the previous denial will be overturned as the services are, medically necessary based on the following review.
Your health plan has completed its review of your appeal for a sleeve gastrectomy (code: 43659) procedure to be performed by (my surgeon) for the treatment of obesity. After careful consideration, it was determined that this procedure will be approved. The reviewers included: an independant consultant who is a board-certified General Surgeon with expertise in Bariatric Surgery, (thee ONLY difference in getting this surgery approved! My pre-authorization was reviewed and subsequently denied by an OBGYN! ) a health plan medical director, and an Appeals Nurse (RN). Please provide a copy of this letter to (my surgeon) with instruction to forward the claim directly to your plan at (address of insurance). This authorization is subject to your eligibility with your plan at the time of service. This authorization applies only to the service previously specified. All deductibles and co-payments will apply in accordance with your health plan benefit plan (100% covered NO copays or deductibles!)
Our physician/reviewer has reviewed your request. Through this program we evaluate the medical necessity of care and the setting in which care is provided.
If you have any questions regarding this decision please call us at (phone number) Thank you for your patience while this matter underwent review.
Sincerely
Dr. *****
Medical Director
Grievance and Appeals Department
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****IF YOU HAVE INSURANCE with bariatric surgery coverage DO NOT SELF PAY FOR VSG UNTIL YOU HAVE EXHAUSTED ALL YOUR APPEAL OPTIONS! Ive read about some people having to appeal 3 times before winning! -or- just get it done if you can afford self-pay and have no desire to fight your ins. company, YOUR call.
Personal note: On 9/10/08 I self-paid in full ..mandatory cashiers check at admission...to have the surgery of MY CHOICE! (VSG) anyway
2 weeks after I filed my appeal (the surgery date was set BEFORE I got that denial letter! Wiped out my savings to boot!) When my denial was overturned hospital submitted bill to my insurance. The insurance company paid the hospital within 2 weeks of hospital billing and Im STILL waiting for the hospital to reimburse my 14.5K !
Edited update: I finally was reimbursed all $14.5K the hospital owed me in April 09.
http://bariatrictimes.com/2009/06/18/laparoscopic-sleeve-gastrectomy/
2009 VSG AMSBS Featured Article
http://www.asbs.org/html/pdf/soard_featured_article.pdf
http://www.ssat.com/video/2008/SSAT%2049th%20Annual%20Meeting(3)-Cirangle.htm
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INSURANCE "I need to save MY life" FIGHTS:
Inquire OH FORUMS- post or repost NEW TOPIC should always have
NAME + STATE of your insurance in the TITLE
Inside post:
Name + State of your insurance
Where you are in the process
A LINK to your insurance's WLS/Bariatric BENEFITS website is EXTREMELY helpful
REASON FOR DENIAL EXACT wording is very helpful!
BMI
CO-morbidities
People want to HELP YOU, not SNOOP!
May have to periodically post if no response. No telling who may have your insurance and got approval that takes a break now and again from forums, or you may have missed someone's post.
Scroll through past insurance related postings for vital information if not to learn about the insurance process, problems, ins. verbiage.
Do an OH search using their search engine with keywords: NAME of your insurance, VSG and where you are in the process..whether denial or appeal
Post insurance questions at Insurance Forum
http://www.obesityhelp.com/forums/insurance/
Contact Shannon Mitchell/ OH Insurance Forum, works for insurance co. May Help w/ appeals
http://www.obesityhelp.com/member/shannonlmitchell/
VSG Forum
http://www.obesityhelp.com/forums/vsg/
Under Forums on OH ...check and post on YOUR STATE'S Forum with those that may have your insurance/surgeon and may have a plethora of info to share
Visit Obesity Action Council Website at:
http://www.obesityaction.org/advocacytools/insurance/oacinsuranceindex.php
Request a Peer to Peer review : your surgeon & consulting bariatric surgeon on Appeals and Grievance Board. Please make sure your surgeon talks w/ another bariatric surgeon!
Contact your STATE's Managed Health Care system (look into your state's online IMR independant medical review claims for ammo on making a case for VSG)
Contact Obesity Law http://obesitylaw.com
HOPE THIS HELPS SOMEONE OUT THERE IN LIMBO-LAND!
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The National Institutes of Health (NIH) is the FEDERAL government overseer for national health care services. They are policymakers, allocating monies/grants for biomedical and behavioral research. Added Update: August 7, 2009 Obama nominated F. Collins, was confirmed by Senate as NEW DIRECTOR of NIH. He is pro research and development, pro preventative medicine, and his religious beliefs will be kept personal and not interfer w/ science nor sway his decision making duties as told to Senate Confirmation Committee
-----------NIH CRITERIA for Bariatric Surgery----------
NIH convened a Consensus Conference in 1991 to determine who should be considered a candidate for obesity surgery.According to the National Institutes of Health (NIH) a candidate for weight loss surgery must meet these criteria:
BMI of 35 or over with 1 major comorbidity
BMI of 40 or over (NO major comorbidities)
Tried and failed reasonable non-operative approaches ( inc. Weight Watchers, Jenny Craig, Nutrisystem, South Beach, Zone, OA, Atkins, etc. Your insurance MAY have a medically supervised diet contingent in its bariatric benefits package. Many states are amending m.s. diets from 6 months to 3 months. Know YOUR policy! CA. does not require m.s. diets because they are a waste of time and money!!)
Psychologically stable
Best possible medical condition
Surgery should be done in a multidisciplinary setting
Definitions
BMI refers to body mass index. This index is an indication of weight taking height into account. Using BMI one can compare in a more meaningful way people of different heights and weights using a single number. You can calculate your BMI from the following formula: BMI = weight (lbs) X 700 / Height (in) X Height (in) or use a BMI calculator.
Comorbidity refers to other diseases such as diabetes, hypertension, and sleep apnea which are directly related to weight.
Failed non operative approaches means that before a patient undergoes surgery she should be knowledgeable about nutritional issues and that she should have tried and failed reasonable diet and exercise approaches to weight loss.
Psychologically stable means that a patient's psychological status be optimized. Any problems in this area should be diagnosed and under appropriate treatment before surgery.
Best Possible medical condition means that a patient's various problems be fully evaluated and under appropriate treatment going into surgery. For instance patients with hypertension should be on drug therapy, people with sleep apnea syndrome should be on CPAP or BiPAP where appropriate, and smokers must quit at least two months before surgery.
http://win.niddk.nih.gov/publications/gastric.htm
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CO-MORBIDITIES
(provide medical history documentation as needed)
Diabetes Type II - metabolic disorder resulting from the body's inability to produce enough, or to properly use, insulin
Metabolic Syndrome- a syndrome marked by the presence of usually three or more of a group of factors, such as high blood pressure, abdominal obesity, high triglyceride levels, low HDL levels, and insulin resistance, that are linked to increased risk of cardiovascular disease and type 2 diabetes; also called insulin resistance syndrome
Sleep Apnea - when a person stops breathing during periods of sleep
Pseudotumor cerebri - increased pressure in the brain which causes chronic headaches and eye problems
Hypertension - higher than normal pressure inside the arteries
Dyslipidemias -abnormal concentrations of lipids in the blood (^cholesterol/triglycerides)
Non-alcoholic steatohepatitis - fatty inflammation of the liver that is not caused by alcohol damage
Venous stasis disease - faulty veins that allow blood to collect in the lower legs
Significant BMI over 35
Significant impairment in activities of daily living
Intertriginous soft tissue infections - infections in excess folds of skin that are caused by obesity
Stress urinary incontinence - involuntary leakage of urine caused by increased abdominal pressure from excessive body fat
PCOS- Polycystic Ovarian Sydrome called a syndrome as it can take on 3 or more of the following:
No menstrual period
Infrequent menses and/or irregular bleeding
Infrequent or absent ovulation
Increased levels of male hormones
Infertility
Cystic ovaries
Enlarged ovaries
Chronic pelvic pain
Obesity or weight gain
Insulin resistance, overproduction of insulin and diabetes
Abnormal lipid levels
High blood pressure
Excess body hair
Baldness or thinning hair
Acne/oily skin/seborrhea
GERD Gastroesophagael Reflux Disease - a digestive disorder that is caused by gastric acid flowing from the stomach into the esophagus
Weight-related arthropathies (joint diseases), orthopedic problems (knee, plantar fascietis, arthritis) which impair physical activity. Weight bearing joints
Obesity-related psychosocial stress - treatment of depression, self-esteem, job discrimination
Failed medically supervised weight programs Fen-Phen, Opti-Fast, Ionomin, Fastin, Phentermine
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IMPORTANT OUTSTANDING ISSUES
(not a comorbidity but will definately strengthen your case)
Need to take daily NASIDS a stomach is required to absorb aspirin/NASIDS
making RNY unsuitable WLS.
ANEMIA
making RNY unsuitable WLS.
Obesity related family history- for ex. colon cancer, hypertension; stroke, Diabetes Type II, heart disease.
