Sadly, they do have the right to deny you, you don't meet their requirements.  You can try to appeal and your FINAL appeal would be a peer to peer.  Don't do it without exhausting your other appeals because they will deny you if you go right to the ins co medical director without going through their stupid process.

Or, self pay.

Usually ins co's require a BMI of 40 without comorbids but with comorbids they will accept a BMI of 35.

The memo has been issued!

www.cms.gov/medicare-coverage-database/details/nca-proposed- decision-memo.aspx

Unfortunatley, and to my great dissapointment CMS has purposed NOT covering the VSG at this time. However, they say they will cover it (ie pay) under a clinical study provided all the required guidelines are met.

Just fired off a email to my hostipitals Bariatric director to see if they meet all the requirements and are willing to participate in the clinical study for qualified patients. Im hoping they will answer under the pretence that the Memo carries over as is to the final decision and not blow me off with something like "ask us again when the final decison is given"

 My Doctor sent ina request for revision surgery which was denied due to not meeting requirements. I'm 5'2' and weigh 185 which puts my bmi at 33.8 but Tricare says it has to be 35.I have highbood pressure and im taking too pills,and I take byetta shots twice a day along with metformin 4 pills a day. They said I can appeal because they say my bmi is 31.89...UGGGG!!!!Help please

I'm writing this because maybe it might help someone.  You REALLY have to be your own advocate.

When I first started this journey I was told by my physician's office that my particular UHC (united healthcare) plan required me to do a 6 month Supervised diet.  I had already known the criteria prior to even going to the surgeon's.  Actually, I called roughly 3 times and each time the rep told me "either a structured diet for 6 months with a physician and/OR weigh****chers, jenny craig".  The coordinator insisited that the reps don't know what they're talking about etc etc.  I went home and called them probably another 6 times and eachtime had them read me the qualifications.  Each time they ALL said the same clause.

Anyhow, to make a long story short, I had my weigh in book from WW (8months worth) and asked the coordintor to please just submit the case and we'll see what they say.  Well, I was APPROVED!  

Make sure you check with your insurance and don't always go by what the dr's office says, sometimes they don't know.

That is all they do. The Doctor is a provider but the Insurance Company is saying the hospital is not a provider. The Doctor's insurance clerk swears that they are a provider since they joined forces with another hospital in the area. I've been hospitalized at the other hospital and if they were out of network I would have ended up with a large bill and didn't receive one bill. This is the web site for my doctor Dr. Glas**** about what they do there for WLS.
http://www.wheatoniowa.org/programs-services/weight-loss-sur gery/default.aspx

My UnitedHealthCare is through John Deere and is also referred to as John Deere Premier. The insurance has changed names so many times we have trouble keeping up, but the coverage stays the same.

I'm looking into a revision from a VBG done in July 1999 to and RNY and when I was trying to get approved for the 1st one I was approved in 4 days.

I have spoken with them before I started this and the insurance company read of the qualifications for them to pay for the revision and I more than meet them. The Doctor’s Insurance clerk has done this for others with this same insurance and says they are getting more and more difficult to work with. She called them to find out I was denied the first time since we hadn't heard a thing from them and they agreed with her that they were a provider and when I called and she called back after getting the denial letter that made No sense we were both told the hospital is not a provider. It all depends on who you talk to and UHC. It's sad to have to go through all this with as sick as I am and this surgery would help me out in so many ways. That is all they do.  The Doctor is a provider but the Insruance Company is saying the hsopital is not a provider.  The Doctor's insurance cllerk swears that they are a provider since they joined forces with another hospital in the area.  I've been hospitalized at the other hospital and if they were out of network I would have ended up with a large bill and didn't receive one  bill.  This is the web site for my doctor Dr. Glas**** about what they do there for WLS.
http://www.wheatoniowa.org/programs-services/weight-loss-sur gery/default.aspx

My UnitedHealthCare is through John Deere and is also referred to as John Deere Premier.  The insurance has changed names so many times we have trouble keeping up, but the coverage stays the same.

I'm needing a revision from a VBG done in July 1999 to and RNY and when I was trying to get approved for the 1st one I was approved in 4 days.

I have spoke with them before I started this and the insurance company read of the qualifications for them to pay for the revision and I more than meet them.  The Docotrs Insurance clerk has done this for others with this same insurance and says they are getting more and more difficult to work with.  She called them to find out I was denied  the first time since we hadn't heeard a thing from them and they agreed with her that they were a provider and when I called and she called back after getting the denial letter that made No sense we were both told the hospital is not a provider.  It all depends on who you talk to and UHC.  It's sad to hae to go through all this with as sick as I am and this surgery would help me out in so many ways.