Dilemma

Okay so before my surgeon submitted for insurance approval, I was told a letter of recommendation would not be written because there were no medical reasons to support my choice in VSG over RNY or lapband. So the denial comes...I ask the insurance coordinator about doc writing a letter to go with my appeal and I said to her I understand he can not recommend the sleeve for medical reasons but if he could just write a letter disputing the investigational part would be great. So she emails me and says Dr Enochs says he can not write a letter because there is no medical necessity, that I should just submit my appeal. Grrr! I know this that is not what I asked! So should I once again try to explain my point that I feel a letter from my surgeon would benefit my appeal process and I am not asking for medical necessity just simply his professional opnion on why the VSG should not be considered investigational or let it go? I feel flustered because I paid a 400.00 consult fee and feel like I am getting not much help but then again I don't want to ruffle any feathers either. Part of me says hell no, demand it and the other part says let it go, he has already said no twice.

Hi Teresa Jay,

I'm brand new to the forum, around 3 minutes to be exact.  I've checked w/ my insurance company, and most insurance companies consider this to be  an investigational procedure, since it's fairly new to the U.S.  This is the information I have, according to my research.

Perhaps you need a new doctor? I think anyone that's overweight and has weight-related problems deserves to have weight loss surgery if it's medically safe.  Why can he not recommend this procedure for you, if you have any weight -related problems, he should recommend it for you. Does your doctor think this is not a safe procedure for you for some reason? Why does he think it's not medically necessary for you? 

These are just questions I'd want the answers to.  Don't know if this was any hel*****t.......
but best of luck!!  I am having to take out a loan to pay for my VSG, because my insurance will not pay for it, but through my flex-spending account, I think I'll try to pay for it that way over the course of 2-3 years. Does that make sense?

Margaret

Hi margaret
Thanks for your reply. My doctor recommended any of the surgeries for me so the VSG is strictly a surgery preference for me so he was saying he wouldn't write a letter because I have nothing medicaly wrong to say VSG is more of a necessity over another surgery. I jusy wanted a letter from a professional stating it should not be considered investigational for my appeal process.

I would be very interested to know exactly what was in the information supplied to the insurer that made them think that there is no medical necessity.  Is it just a matter of a referral from your PCP listing co-morbidities that would be resolved or at the very least improved with successful WLS?  If you paid $400.00 for a consult with your surgeon, you are entitled to a letter of recommendation that at the very least lists the medical issues you have and how weight is a significant factor in if not their cause, certainly the symptoms.  Do you have a high BMI, high blood pressure, asthma, sleep apnea, arthritis, etc?  If so, you have a medical necessity.  If he absolutely refuses to help you, I say it's time to start looking for a better surgeon.  If he performs VSG and agrees that it's the best choice for you, he should be trying to get you approved at the very least because if he doesn't, he's losing significant funds from the insurance company because you'll find a better surgeon.  Once you cross that hurdle you can start with the VSG "investigational" issue (there are several in this forum who have written letters on the investigational issue as well as VSG being the best option for certain populations and they  would be sure to help at that point I'm sure).

I say ruffle some feathers.  Insurance companies (I used to work for one and was a licensed agent) are huge corporate monsters and unfortunately the first response to a claim is simply denial knowing that 90% of people won't pursue an appeal.  In the case of insurance, the squeaky wheel gets the grease.  You don't have to be "difficult", just assertive.  Call the insurance company directly and ask to speak to a supervisor in customer service.  Ask specifically why the decision to deny coverage was made.  Ask specifically what steps are required to meet the "medical necessity" requirement.  Make sure to keep a detailed list of with who you spoke, date, time, and what was said.  These are important for any successful appeal.

Take control of this issue; don't rely on what the insurance coordinator is telling you.  Be assertive and realize that taking responsibility for this is just one of the many ways WLS is going to empower you.  You chose VSG because it was the best choice for you; now make sure you do everything within your power to make it happen!

Amy

Hey Amy
You always have great advice and I love the fact that you put a 110% of genuine concern and heart in your responses. I do meet the medical necessity for my insurance company but they only cover RNY or lapband....vsg is considered investigational. I have written an awesome appeal letter (I think anyway) with the help of all my friends here ofcourse with advcie and research links. So that is why my doctor is saying he wouldn't recommend the sleeve over the other surgeries for me because I have no GI problems that would say the sleeve is a better option medical wise (I don't have to have VSG, I could have RNY). It is simply a preference and I could have any of the surgeries. I have an appointment with him on the 18th so I might just wait until then and speak with him in person to see if I can make my point of him just writing a professional opinion that the sleeve should be covered along with either RNY or lap band and it shouldn't be considered investigational. I just didn't want to wait that long. I wanted to get the ball rolling but perhaps MacMadame is correct in saying the request is getting garbled by a third party so maybe I should just speak with him directly on the 18th. I love Dr. Enochs, some of his staff have not impressed me so far. They make me  feel it is too much trouble for them to fight and would prefer me to just "settle" for the RNY since insurance is willing to pay for it. But they don't have to live with that choice...I do! So I told her I would fight, that just getting it doen quickly, however way was not an option. In my consultation Dr Enochs was very supportive in my decision of the sleeve, he was just upfront in saying it is hard to convince the insurance companies to pay for it especially considering I have nothing to validate the sleeve over RNY , other than preference....but it was my choice.

Well, I think that having VSG over another surgery is a personal opinion so I understand what your doctor is saying... why don't you just find articles that dispute the investigational reason along with articles that discuss the problems with lapband (you can attach this to an appeal letter) and write an appeal letter that may appeal to them emotionally.  Do you have emotional reasons for wanting the VSG over RNY?  RNY has malabsorption problem, do you want to have children in the future?  Are you considered a "lightweight"?  I'm sure you can find lots of benefits of VSG over RNY in your own research...

I suspect that your message to the doc was delivered garbled. Could you email him so it's in writing with no misunderstanding as to what you want?

And if he thinks it's experimental, maybe you could get some other surgeon to write the letter??

Aloha TJ- Get a face to face - your insurance company should be handling these visits as you haven;t had surgery yet, these are just consults. Remind your doctor that you have a huge need for NSAIDS due to blah blah blah ( chronic headaches, sore back, stiff knees. unbearable menstrual cramps) and that tylenol and celebrex simply do not give you quality of life  that you need the ulcerogenic ibuprofen/naprosen/feldene/ whatever drugs. I think that RNYers and lapbanders cannot take these meds. Then remind your doctor that he is your advocate, you are his patient, and that you are approcahing this as a team in order to have the most successful outcome and that having the shortest procedure possible with the fewest complications is your ultimate goal. That should line up VSG as well. But you need to talk to him in person, I think. Sigh. I don;t know about you, but I pay VERY hefty premiums for my insurance coverage. WeI shouldnt have to battle them to improve our health. XOXOLori

Well- again this is just my opinion. I choose VSG because it was safer and they don't touch my bowels. But if my doctor recommend the RNY - I would do an RNY because overall the results are about the same- I was told, by my physical weight loss is the same. My thing - is weight loss is weight loss- My insurance covers both but if it didn't I would do an RNY because I need to loose the weight.

So as someone said earlier, might have to find another doctor or keep appeal, or just do the RNY.

I am at a point in my life, no turning back, don't matter how much it costs me, and how much of my vacation I might have to use, I need this weight off because it's affecting my every day life.

Every time I have pain, or back pain, or the diabetic effects, or pain in my knees or unable to play with children, or so tired- I say ANYTHING I hvae to do.. I will do it. .

I am doing what I can right now to loose what I can- but I am READY!!!!

I pray that everything works out for you , in what ever decision you make.

Carmen