Keith

Brittu: Don't be hard on yourself. If "control" was all it took, we would not need this surgery. I have the operatory notes from the surgery. They were submitted to BCBS for the Level 1 appeal. From what they have told me they felt that they had no recourse under my plan but to deny my claim at the first level because VSG is not a covered service. They have indicated that they have more latitude at the second level and could at least cover some of the expense. Because mine turned into an open surgery I am dealing with much more than the cost of a used car. My doctor did write a letter explaining that he went to "extreme" measures to perform the gastric bypass but that this was not possible due to my unique anatomy. Because I was open he stated that he "had to perform the surgery" and did the "best procedure he could perform" due to my situation. He is a Center of Excellence surgeon who has a solid background with the Roux-N-Y so he should know if it could not be performed. He certainly did not appreciate the first decision which suggested that he could have done a lap band or a VBG. I was not a candidate for the lap band for several reasons. Apparently, the VBG is a "historic" operation and definitely not the standard of practice according to my surgeon. In fact, Medicare no longer covers it and I read that the AMA considers it an "extremely dangerous" operation. Could you please point me to Theresa and, I think it is McMadam??, whom you mentioned in your response? I would like to read their VSG posts. Best of luck and thank you! Keith

I think your appeal is well written and appears well researched. I am interested in the source of your data for Fed BCBS coverage of VSG. I am engaged in my own appeal although my situation is different. I went into surgery for a Roux -n-Y after my insurance (a self-insured plan administered by BCBS) denied the VSG as experimental/investigational. Well into the surgery (opened BOTH laproscopically and fully) the surgeon determined that the Gastric Bypass was not feasible due to my unique anatomy. He converted to a VSG after giving my wife that sole option simultaneously with the news that my liver was "foi gras" due to my obesity. Now, the insurance which pre-authorized the Gastric By-pass doesn't want to pay. On the plus side, I have lost 100 pounds in five months and feel no hunger. I have been able to also get off the Metformin for my Type 2 Diabetes. All is not roses; no one would choose this if they had a real alternative to surgery.