Today, in tears over non-coverage of VSG...

[lapfish 0]

Group,

I was scheduled for surgery on 9/24 with Dr. Metz, in Denver. His billing clerk called today and said that she called a 5th time today to my insurance, Federal BCBS. She spoke with the pre-cert dept this time and got an R.N. on the line. The R.N. said the VSG with CPT code of 43843 was not covered. I called twice and the billing clerk called twice before this and we were both told that it was a covered service. I am extremely depressed and upset. I refused to have my guts re-routed or some foreign part in my body. (sorry to be so blunt) I am completely confused as to why 4 different ppl would tell us that it is covered and then pre-cert R.N. says no. I called back and I was told that I could talk to an M.D. with pre-cert if I wanted but it wouldn't change their decision. I am just screwed now.:001_wub:

[Tiffykins 673]

Don't give up, call and see if you can appeal the decision. I could of sworn that someone else had won an appeal with Fed BCBS. Check on OH, if you haven't already as well.

I'm really sorry, and I'll keep you in my thoughts.

[MacMadame 81]

I know penty of people with BCBS Fed who got a VSG covered. There could be two things going on:

1) The clerk made a mistake. This happened to me ALL the time when I was dealing with insurance and calling them. You'd call one day and get one answer and call another day and get another answer

2) Your company may have a variation on the policy that makes it not covered for you even though it's covered for other people at other companies

You just need to keep pushing. Insurance companies behave like this because they COUNT on you to give up even if you were in the right.

ETA You aren't screwed. There is an appeals process and you can and should take advantage of it.

[babygirlinokc 0]

I agree you are not screwed. Appeal it. That is what I'm doing. :tongue_smilie: We have one of the best insurances in the country and to be federal employees th government is supposed to have really good benefits. It should not make a difference of region we live in. I already called OPM and they told me it did not matter what state you live in with BCBS Federal you only have to meet the criteria. I'm sending out my appeal today after work. I'm not giving up until I win.......If I don't win at least I tried........

babygirlinokc

[cajun 46]

Ask what their criteria are for approving a VSG.

Read the article at SpringerLink - Journal Article

You will find good info there on your rights.

Don't give up....ever!

[lapfish 0]

I was just told yesterday by Federal BCBS that the reason they won't cover a VSG is because we are Federally bound with our insurance. If it hasn't been FDA approved, we can't get it done. They have to go by medicare guidelines and medicare is not covering it. It is still considered experimental, even though other insurances are covering it. I am at a loss. My hands are tied when they tell me that. I even went through Pre-cert dept and asked them with the CPT code of 43843 and they wanted to know the procedure name and then told me no. Until the medical board with the insurance meets again, which is every quarter, we won't know if they will cover it. I want it done now because my catastrophic cap has been met. That means I would pay ZERO for my surgery, doc, hospital, meds and all. I just don't know what to do.:tongue_smilie:

[Manatee 0]

Is the Duodenal Switch on the approved list?

You know, the VSG is just the first part of the switch, and most patients have that part done first and then the gut rearranging done later. Perhaps if you just don't return for the second stage....

[Bob_350lbs 105]

www.obesitylaw.com helps w/appeals. I like manatee's idea too. Also, for those of use who had hiatal hernia repair as an incidental to the VG, got me thinking, what if the surgeon just billed for a hernia repair? Wouldn't they cover that? This whole insurance issue sucks, I know. The VSG has stats as good as the RNY, even long term out.

Don't they realise covering a simple VSG procedure will save them millions in the long run?

Edited September 18, 2009 by Steph_123

[lapfish 0]

I know penty of people with BCBS Fed who got a VSG covered.]

Can you give me states and some names of these people that got it covered? I need to try and get this straigtened out before the new year. Right now, I would pay ZERO for the surgery b/c cat. cap is met. Thanks.

[Pink Stella 0]

I have BCBS NC and that code is covered. I know each insurance is different, but I was given a CPT code of 43659, which is also a covered procedure. I looked both of them up (https://catalog.ama-assn.org/Catalog/cpt/) - and the description for 43843 is "Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty " and the description for 43659 is "Unlisted laparoscopy procedure, stomach."

You might contact your HR department, too. Find out if the fed is self-insured. I work for a municipal government and we are self-insured. That means that the city itself determines what coverage is offered and BCBS administers the insurance. If you're willing to discuss it with your HR rep, they might be able to help you out.

I'm not sure if any of this will help you at all. Good luck!