Question:
I receive a letter from my insurance, BCBSNC,which stated that I was denied for the V
SG surgery,because it was investigational services. What does that mean and what should I do in order to get approved? — brainey62 (posted on January 6, 2009)
January 6, 2009
There is no insurance that will cover this type of bariatric surgery.
Insurances are notiously slow in approving any new procedure/medication. I
understand that this is a very effective surgery, but if you need to have
your insurance pay for it, then you might want to consider the gastric
bypass surgery instead. I had it done on 12/3/08 and everyone I have talked
to that has had it feels it is the quickest way to lose the weight.
Good Luck in your journey!
— joycedev
January 6, 2009
It means they consider it experimental or unproven. You can try an appeal
but I would start by calling your insurance company and ask them which
weight loss surgeries are covered, and if there are any conditions or
pre-requisites like minimum weight standards, co-morbidities, etc. Then,
unless you can self-pay, you should consider the other WLS options out
there. Most bariatric surgeons offer free seminars where they explain the
surgeries they do and the benefits and negatives of each. They encourage
you to ask questions so go prepared. I sympathize. It's a hard decision to
make and more frustrating when you've actually made one and then find you
can't get it. Keep researching and good luck.
— Arkin10
January 6, 2009
I have BCBS of Michigan and they approved the VSG for me with no problem.
I really dont understand how one branch of BCBS can approve and another
state it is experimental.
— DanaRhea
January 6, 2009
Most BCBS consider it experimental and will not cover it. Your best bet is
to go with the RNY.
— tonitoot
January 6, 2009
One thing you may want to try is to have your physician or surgeon write a
letter stating that he considers the VSG the best surgical option for you
when in comparison to the others. If the surgery is deemed "medically
necessary" by a medical professional, many insurance companies WILL
pay for the VSG. They just need that paper SAYING that it is medically
necessary. Otherwise, you are probably stuck with the Rny, or
"Gastric Bypass." I personally feel the VSG is the better
option, because there are far less complications, and it is almost exactly
as effective, but you take what you can get, unless you are willing to pay
for the operation yourself.
— hubarlow
January 6, 2009
— nursenut
January 7, 2009
Wow, not to pick on any above posters, but you've gotten some
misinformation. First, the VSG is NOT the 'vertical banded gastroplasty'
it's the vertical sleeve gastrectomy. Second, yes there are insurance
companies paying for the VSG; Federal BC/BS started covering it 1/1/2008.
Please go to the VSG forum on this site, I know of at least one person who
was also denied by BCBSNC who has posted there. Personally, I wouldn't opt
for the RNY just because insurance will pay for it. If you feel VSG is
right for you, call your insurance company and find out the steps to begin
the appeal process. You may also wish to contact an attorney specializing
in obesity law to help you craft your appeals. You need to demonstrate
medical necessity for this particular procedure as well as submit
information (studies, etc.) proving its efficacy at treating obesity.
Depending on your BMI, you may also submit as a two stage DS (the VSG is
the first step of the two step procedure). Hope that helps!
— Privacy Please
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