Question:
BC/BS had a meeting the other day about laprascopic WLS
and according to my surgeon BC/BS is trying to make it their policy to consider laprascopic WLS experimental and therefore not cover it.My surgeon thinks its because the insurance companies are afraid that to many people will want the surgery if they don't have to go through the "open" procedure.This sounds like a trick that the insurance companies might try.Has anyone heard this from their surgeon? My doc is going to submit for authorization for either laprascopic or open procedure and see which one they will cover. — natalie J. (posted on August 24, 2003)
August 24, 2003
Just curious how would you or your surgeon know this? BC/BS is usually not
too forthcoming with things they are thinking about. Not even too
forthcoming once they have made a decision.
<p>Most people who have BC/BS have it through their employer and it
comes down to what the employer wants to cover etc. If you are talking
about a standard BC/BS policy that anyone buys off the street then it is
possible. However, the cost difference is only about $3000 so it's not
like an open saves them much.
<p>I cannot imagine anyone who truly needs WLS, for medical reasons,
would refuse this life saving surgery because they could only get an open.
If they would, then they really need to be figuring out what their motive
for surgery is. It wasn't my insurance that decided I could not have LAP
it was my surgeon. For the super morbidly obese, and I suspect most
morbidly obese, what is a scar when you are alive to enjoy life? It's
nothing!!!!!
<p>If your doc submits for both you can just about guarantee they
will only approve the open. I would ask for the LAP and if they deny find
out why and if it's because of the LAP then change it to open. I do not
believe BC/BS will get by with doing something like this and even question
if they are considering it. It is a proven fact that LAP procedures of any
kind are less invasive and quicker healing so I do not know how in a court
of law they could win not allowing it. It's not like it's experimental.
— zoedogcbr
August 24, 2003
Yes, my surgeon just mentioned this to me the other day except he said that
BC/BS federal were no longer approving the lap RNY, which is what I had and
the insurance I had 18 months ago-it was one of the easiest insurances to
have and get approval. And he did say they were classifying it as
experimental. What it means for me today, is that they are now denying my
follow up visits with the surgeon even tho they approved them all during my
first year post-op. I think since this surgery became so popular the
insurance companies are paying out too much and are looking to pull back.
What they don't understand or haven't fully looked at in my opinion is the
statistics on savings from not having to treat obesity and its
co-morbidities after a person has this surgery. They have also made it very
difficult for surgeons to get malpractice insurance and many have stopped
doing these surgeries because of it.
— Cindy R.
August 24, 2003
My surgeon mentioned smething about this too. LAP is paid for because
although the actual surgery costs more the hospital stay days is less, and
it just about elminates the incisional hernia problem. Follow up surgeries
to fix hernias cost lots of mooney too. It sounds like they are cutting off
their nose to spite their face.
— bob-haller
August 24, 2003
My SURGEON also referred to Lap rny as "experimental" actual if a
procede is considered expirimental is not necessarily determined by the
insurance co. but by the FDA.
— **willow**
August 24, 2003
I highly doubt that what you heard is true as stated. That simply is not
how BC/BS determines whether a procedure is experimental. They use a very
long, drawn-out, scientifc process based on medical studies, governement
guidelines and a number of independent indicators. In fact, they are so
deliberate in their process, that they often lag behind other insurers in
moving procedures out of the experimental category into the
generally-accepted category. I have never heard of an insurance company,
and certainly not BC/BS, going backwards in determining that something that
was once not considered experimental now is. Perhaps there's some small
bit of truth buried somewhere in here (perhaps they consider lap
experimental in super obese patients, for example), but the story laid out
here is just not how it works (I used to serve on a BC/BS claim
grievance/appeal committee, and the issue of experimental procedures came
up frequently, so I have first-hand knowledge about this).
— Vespa R.
August 24, 2003
Natalie: I'd be extremely interested as to why the company considers lap
RNy experimental... hmmm.... While the lap procedure does greatly decrease
(although not eliminates) the chance of incisional hernia, there have been
some SERIOUs cases of internal hernias/mesentary hernias happening as a
result of the lap procedure. This happened to me! I had a lap DS and two
years out I survived (by the grace of God) an internal mesenteric
hernia/complete blockage. The intestines got stuck in the tiny lap holes
that were left when the instruments were pulled out. It was not customary
at the time to hand sew the lap portal sites (Mt. Sinai where I had my
surgery done has made this standard as of Jan' 03, I'm not sure about other
places). I had 3-5 feet of intestines removed and multiple blood
transfusions. Although this is a very *rare* complication, I have known it
has happened to many people - seems to be far greater than the '3 pct.'
blockage rate normally quoted.
What happens is that the holes in the mesentary (the lining surrounding the
small intestines) expand with weight loss (because of a loss of internal
fat) and part of the intestine can become strangulated in it.
*I honestly don't know if this has ANYTHINg to do with the whole
'experimental' label.. certainly trying to discourage people from having
any WLS done is a viable possibility... but could you ask your surgeon for
specifics? I'm very interested about this... All the best,
TEresa
— Teresa N.
August 24, 2003
This could explain why my surgeon codes his authorization requests as OPEN
instead of LAP (he prefers doing the surgery LAP).. I imagine this is
legal because there is the possibility that the surgery can be converted to
OPEN if there is a problem...
— SJP
August 24, 2003
SJP - The only problem is that your surgoen is willing to do LAP for the
cost of open but I bet the hospital isn't. It costs them more for
sterilizing the scope etc. Also OR time is usually longer etc. I'd be
real cautious of this being paid correctly.
— zoedogcbr
August 25, 2003
But this doesn't make any sense. The surgery is the same regardless of how
the surgeon accesses the abdomen. If they are saying the RNY is
experimental, then I would think they would stop approving both LAP and
OPEN. If they are saying LAP is experimental, then they would not approve
other types of surgery that can be done laprascopically(gallbladder,
appendectomy, etc.)
— Ali M
August 25, 2003
I have BC/BS and they had no problems approving my Lap RNY.
— Debbie R.
August 25, 2003
I was approved for lap rny by bc/bs health options surgery was 8/11 the
first answer I got was it was considered experimental I ask the rep from
bc/bs what to do,she said the doctors office may have summited it under the
wrong code. My doctors office called got it fixed and I was approved within
about 3 days.
— Shannon S.
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