Getting approved for 2nd stage DS

Umpiregator
on 9/23/20 6:16 pm

I am trying to get approved for 2nd stage DS. Had an upper GI done which showed no issues. My BMI is 36.5 with comorbidities. What are my chances of getting approved? I have BCBS of FL.

califsleevin
on 9/24/20 9:59 am - CA

On the surface, it should be approved, as typically a revision such as this is treated the same as a virgin WLS - you need a minimum BMI of 40, or 35 with comorbidities. Some policies may only require one comorbidity while others may require two or more. The other main roadblock is that some policies limit patients to one WLS procedure per lifetime, so that eliminates revisions (at least for weight problems; resolving complications puts it into a different category.) Also, some policies may limit the DS to higher BMIs, such as 50 or 60 and above.

Another wrinkle is that some policies may not approve a two stage DS - this is usually a throwback to when the VSG was still "experimental/investigational" and some people were using the 2 step DS as a backdoor way of getting a VSG (go in for the VSG stage and never show up for the second "switch" part.)

You can check the policy bulletin that covers your specific policy's bariatric benefit online and that should tell you what you need to know about its limitations. You can also call your company's customer service line and ask, but they don't always get things right. If you already have your surgeon lined up, they should have an insurance coordinator in their office who understands "insurance-ese" and can interpret the policy for you.

1st support group/seminar - 8/03 (has it been that long?)  

Wife's DS - 5/05 w Dr. Robert Rabkin   VSG on 5/9/11 by Dr. John Rabkin

 

airbender
on 9/28/20 7:39 pm

no one will be able to answer your question of chances getting approval, as your subscriber agreement is yours, it is what your employer has purchased and your BCBS or FL is not the same as other BABS of FL. You have to read your subscriber agreement, pay attention to the exclusions, etc.

One thing that is difficult with the DS is this VSG standalone and DS. This has become more difficult getting the intestinal bypass after you had the VSG via insurance approval as it appears as a 2 surgery bariatric procedure. If you had the VSG due to surgical issues....in other words you went in for a DS and the surgeon could only perform the VSG, that would be easier to argue, I have noticed the get the VSG and wait and see then request the DS have been more difficult to appeal, as the argument can be made as this is the 2nd procedure. good luck!

If you have a specific question for me, PM me or I will not see it, as I don't check responses on the forums and don't have anything forwarded to my email.

woo woo
on 10/5/20 7:34 pm
VSG on 09/08/14

I was able to get approved with BMI 35 and 1 comorbid (hypertension ). There is a lifetime dollar limit on Bariatrics for my policy, but after sleeve I still had about 2/3 of money limit still remaining. Plenty left for DS revision. HTH

Umpiregator
on 10/18/20 5:27 pm

Update: Insurance approved me on Oct. 5th. Just waiting on a surgery date now.

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tinker916 · 5 replies · 147 views
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