Pacificare POS San Diego, CA Appeal Help

Ok, I am putting on my game face. I was denied for VSG stating that it is not covered under insurance plan and that's the only reason why. I qualify under the Lap Band and RNY which they cover but I wanted VSG. While talking to the Insurance company a few weeks back I was told that all I had to do was prove why this procedure will work better than the others that are covered.

Well, I am not sure how to start this letter and process. My BMI is somewhere between 51-53 (depends on who's calculating it), I have a history of Gestational Diabetes, Hypertension, and a femaily history of Diabetes, Hypertension. Oh Lower back pains, anemia, my bones really do ache from all this new and old weight I am carrying. I have had irregular periods and problems with pap smears and child birth which the nurse said losing weight would fix (I fixed myself and tied my tubes). So if there is anyone out there that is familar with the appeals letter first step please help!!!! Also if you have examples of a letter and don't mind emailing them to me please do so [email protected]. Thanks everyone!

Tracy, this question came up recently on this forum, and unfortunately I think you're going to have a rough time of it. The good news is that every health insurer is required to have some kind of appeals system by federal law, so if you contact your insurer they will tell you how to file an appeal. Further good news is that, in CA, you have the right to external appeal to the DMHC (dept of managed health care) after you exhaust your internal appeals.
    Now the bad news - it is doubtful that the DMHC will overturn your health plan's denial for the VSG because it is still considered investigational. There is no knowledge of longterm results with this operation because it has been done as a "stand alone" operation for only a few years. Moreover, the 3-5 year results that are just becomming available don't look better than for RNY, so it is doubtful that the DMHC will force your insurer to cover something that isn't better than what they offer. A further problem - for people with higher bmi's, the results with vsg even short term are not looking good at all.
    There will be some people who are very successful with vsg. But when you look at large groups of people, which is what insurers and reviewers do, the overall results are not great.
     However, there is another alternative for you to consider. Have you looked at all at the duodenal switch? The vsg is the top half, so to speak, of the DS. The DS has been around since 1988 and there is documentation in the medical literature of the excellent results in excess weight loss, maintaining that weight loss, and resolution of comorbidities - all superior to rny. It has the best rate of resolution of type 2 diabetes of any wls - 98%. Like the vsg, it would allow you to take NSAIDs, to drink liquids with your meals, and eat a more varied diet than rny or lap band. And no dumping. Also, even if your insurer doesn't cover it, the DMHC review almost always overturns denials in favor of the DS.
    Come on over to the DS forum and learn more about this operation. And if you want to read some articles about it for yourself, send me a pm.

Larra