HELP! TRIWEST - CA does NOT COVER LAP FILLS?

Can anyone help me with this process.  Had lap on 4/1, no resistance yet as no fill.  Have lost weight and inches, though, on my own.

Fills are done w/ fluoro, but biller at MD says that TRIWEST won't pay for injejction, or outpatient radiology visit.

CAN ANYONE IN THE STATE WHO HAS A LAPBAND and DOES FLUORO FILLS HELP ME?  The fills cost $600.00 and I just got laid off from my job - I had BC PPO prior to Triwest, so don't know excactly how to navigate this system.

Thanks so much for your help and your support!

I think you should post this on the lap band board.  there is a woman on there that is a great insurance guru!  The band is no good without the fill, so your insurance company has failed you!
I have never had my band filled with fluro or a radiology visit.
Good luck to you!

Did post on lapband board and have gotten one response.  Will let you know what I discover. Thanks for the support.

Well, this is what i can tell youYou shouel contact Lauries office they have been paid for the surgery and you should at least be covered under the global period for the surgery within the first 90 days. I suggest you call and ask to speak to the office mgr. I think his name may be David. They got paid they need to more than likely cover you for the 90 fay globabl period..
Good Luck
Liz

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Adjustment of Gastric Band after Bariatric Surgery

Bariatric Surgery falls under a Medicare National Coverage Determination (NCD 100.1, ref. 1.) All bariatric

surgeries which are payable by Medicare must be performed in an approved facility. Gastric banding (e.g. “Lap

Band") is one of the covered types of bariatric surgeries. There are a series of specific CPT codes for gastric

band placement, revision, replacement, port removal, and other related surgeries (CPT codes 43770-43774 and

43886-43888). Specific local coding guidance for bariatric surgery is provided in NHIC’s Local Coverage

Determination (LCD) for Bariatric Surgery (ref. 2). This guidance provides details of coverage which are not

available in the NCD.

Gastric Band Adjustment

There is no specific code for an adjustment of the gastric band. Note that within 90 days of the original surgery,

adjustments fall within the (bundled) global period for post-operative management. There is no separate new

payment for staged adjustments that fall within the surgical global period.

Medically necessary adjustments outside the 90 day global period may be coded with CPT code 43999, unlisted

procedure, stomach. State "Gastric band adjustment" in the comment field for this unlisted code. Do not use

CPT code 90779, because this code is specifically for “intra-arterial or intravenous" injections.

Fluoroscopic guidance, if used, may be coded as CPT code 76000 {Fluoroscopy (separate procedure), up to 1

hour physician time}.

Evaluation and Management (E/M) associated with Gastric Band Adjustment (43999)

An E/M service may be charged (using modifier 25) if it is separately identifiable from the actual adjustment. For

example, an appropriate evaluation of the patient’s new complaint(s) or management issues, interval history,

physical examination, medical decision-making, etc, is payable along with the adjustment procedure itself. If the

patient had such a visit and decision-making previously, and is simply returning for the procedure, a separate

E/M service should not be charged.

Editing of Gastric Band Adjustment (43999)

Claims for gastric band adjustment are not edited as stringently as the primary bariatric surgery. For example,

the site of service does not have to be a bariatric-approved hospital and the ICD-9-CM code(s) may be different

than the original surgery (for example, the patient in question may no longer have symptomatic diabetes as he

did before the original surgery one year earlier.) Gastric band adjustment is not part of either the NCD or LCD

on bariatric surgery, and therefore reasonable community standards apply for medically necessary adjustments

Liz,

Thanks so much for your help.

The doctor who is doing the fill is not the same person who did the surgery, so I'm not sure what's going on. I appreciate your help. I originally went to Dr. Laurie's office and was told by his biller that my insurance was not accepted by him, so I had to find a different dr. I chose USC because the neurosurgeon who dealt with my strokes is there and was familiar with my case.

I will contact Dr. Katkhouda's office at USC tomorrow and ask the office mgr (not a very nice person) why my first fill is not covered, or do you think I should contact TriWest first to determine if the fill is covered under the first 90 days of surgery. Is something I should have the insurance battle with the provider, or just see if I can get the insurance to pay the doctor using the referal process?

Thanks again for your help. I appreciate your time more than you can know.

Mo