"Investigational?"

[journiewilde 0]

Hi all, I have Wellmark BCBS of Iowa and am about two weeks away from submitting pre-approval, so just reading over the WLS coverage on their site. VSG is listed as "investigational", which is bolded like it's important, but not explained. RNY gastric bypass is listed as "may be medically necessary when criteria below are met".

I am having zero luck finding a good explanation of what the difference is, on the site. Can anyone clue me in to what that means in insurance terms, and what it may mean to my preapproval application?

If it matters, my BMI right now is 49.6.

Also, anyone else have Wellmark Iowa (not federal) and have any luck?

Thank you for any help!

Here is the verbiage from the website:

Medical Policy: 07.01.17

Original Effective Date: September 1995

Reviewed: September 2009

Revised: September 2009

Benefit Application

Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description:

Obesity is the most frequent form of malnutrition in the developed world and it is increasing. Morbid obesity (i.e., obesity with secondary serious or debilitating progressive disease) is generally associated with a body mass index (BMI) of ≥40 kg/m² (i.e. weight/height squared). Morbid obesity has a significant impact on cardiac risk factors, incidence of diabetes, obstructive sleep apnea, debilitating arthritis of weight bearing joints, infertility, psychosocial and economic problems and various types of cancers, etc.

The first treatment of morbid obesity is dietary and lifestyle changes. When conservative treatment fails, a few patients may require a surgical approach. The National Institutes for Health defines potential candidates for surgery as those with a BMI of 40 kg/m² or more or a BMI between 35 kg/m² and 39.9 kg/m² and a serious obesity-related health problem such as type 2 diabetes, coronary heart disease, or severe sleep apnea. Additionally, persons should have acceptable operative risks, the ability to participate in treatment and long-term follow-up, and possess an understanding of the surgical procedure and necessary life style changes.

Surgery for morbid obesity, also known as bariatric surgery is based on intestinal malabsorption and gastric reduction. Surgery is considered successful if weight loss is maintained at greater than or equal to 50% of excess body weight for more than 10 years.

Several different gastric reduction and intestinal malabsorption procedures are listed below:

Gastric reduction (gastric restrictive) procedures:

* Vertical-banded gastroplasty

* Adjustable gastric banding

* Gastric bypass (Roux-en-Y gastroenterostomy); this can be done by both open or laparoscopic approach

* Mini-gastric bypass (laparoscopic)

* Sleeve gastrectomy; performed on its own or in combination with malabsorptive procedures.

Malabsorptive Procedures:

* Biliopancreatic bypass (Scopinaro Procedure)

* Biliopancreatic bypass with duodenal switch

Top

Prior Approval:

Prior approval is recommended for this service. Submit a prior approval now.

Top

Policy:

The following surgical procedures for the treatment of morbid obesity may be considered medically necessary when the criteria listed below are met:

* Vertical-banded gastroplasty

* Gastric bypass (Roux-en-Y gastroenterostomy) with short Roux limb equal to or less than 150 cm; this can be done by either open or laparoscopic approach

* Adjustable gastric banding (Lap-Band® procedure)

* Biliopancreatic bypass (i.e., the Scopinaro procedure) with duodenal switch; this can be done by either open or laparoscopic approach

Criteria for Coverage:

* Patient is at least 18 years old

And

* The patient must have documentation in the medical record of failure to sustain weight loss within the two years preceding surgery and documentation of the health care provider’s monitoring of the patient’s progress toward a goal of weight loss.

And

* The patient must be a motivated individual with acceptable operative risk and must be evaluated by a licensed mental health provider to determine the patient's willingness to comply with pre and postoperative treatment plans, and a strategy to ensure cooperation with follow-up must be documented.

And, in addition to the general requirements above, the patient must also meet one of the following weight criteria:

* BMI of 40kg/m² for at least 3 years

* BMI of ≥ 50 kg/m² for biliopancreatic bypass (i.e., the Scopinaro procedure) with duodenal switch

Or

* BMI of greater than 35kg/m² in conjunction with at least one of the following:

o Hypertension requiring medication for at least one year

o Diabetes Mellitus type 2 requiring medication for at least one year

o Obstructive sleep apnea, confirmed by sleep study, which does not respond to conservative treatment

o Documented cardiovascular disease

o Pulmonary hypertension of obesity

The following surgical procedures for the treatment of morbid obesity are considered investigational:

* Sleeve gastrectomy as a stand alone procedure OR in combination with a malabsorptive procedure

* Mini-gastric bypass (laparoscopic)

* Biliopancreatic bypass (Scopinaro Procedure)

* Long-limb ( > 150 cm) gastric bypass

Endoscopic procedures, including but not limited to the StomaphyXTM device, to treat weight gain after bariatric surgery due to large gastric stoma or large gastric pouches are considered investigational.

Bariatric surgery is considered investigational as a cure for type 2 diabetes mellitus.

Subsequent bariatric procedures, including revisions, in patients who regain weight due to failure to comply with lifestyle or dietary modifications are considered not medically necessary.

[Eureka-C 20]

I was initially denied coverage due to the sleeve being investigational. In other words, there is not a 10 year history of maintained weight loss documented in the journals, as it is not 10 years old as a stand-alone procedure. That being said, there are various medical reasons why the sleeve is accepted such as a requirement of taking NSAIDs or diseases such as crohn's. I do not have anything like these problems, but I appealed based on a family history of diabetes and a personal preference to not have malabsorption issues et cetera. I won my appeal and I am scheduled for surgery on November 22 nd.

If you are interested in the RNY, your post describes the qualifications clearly and with your BMI, you will likely be able to meet them with no problems. Personally, I do not recommend the RNY or band, but I am not a health care professional, and it is my personal preference.

Do you have comorbid problems? These can be important to your choice.

Good luck!

[WeekendWarrior 0]

Wellmark currently will not cover it due to it's "investigational" status. I don't know if anyone has tried to submit to them lately though. Your Dr.s Insurance specialists might know more than anyone.

If you haven't I would start working on the 6 month suppervised diet requirement.

I've lost 60 pounds during my 6 month diet so far, and I am now kind of waffling on if I should continue trying to lose or not.

My BMI was 50, and now it's 41. I can get down to 35 and still be approved as I have several co-morbid conditions.

[WeekendWarrior 0]

I just called my Dr. office and and asked them if they have heard if Wellmark is covering the sleeve yet.

Their insurance person said that there is supposed to be an annoucement next week some time.

So you might want to start getting your paperwork ready, you could be the first person approved by Wellmark!!!!!!!!!!!!

[journiewilde 0]

That is crazy awesome! I am hoping to have all my ducks in a row to submit by the 19th or 20th, so if they suddenly started covering VSG without a hassle. That would be absolutely amazing. What (potentially) great news! Thank you.

As far as traditional qualification, I would certainly qualify for RNY, but I do tend to take quite alot of NSAIDs (though for generalized pain and frequent headaches, not really for any real documented 'condition') and don't have any 'official' comorbidities, just a family history of diabetes and obesity, and some back and joint pain. Mostly, I'm trying to stop the train before it rolls too far downhill.

Last psych consult and a wrap-up appointment with the surgeon's PA on the 19th of October, and submission after that... Wish me luck!

Thank you for everybody's responses.

[journiewilde 0]

I just called my Dr. office and and asked them if they have heard if Wellmark is covering the sleeve yet.

Their insurance person said that there is supposed to be an annoucement next week some time.

So you might want to start getting your paperwork ready, you could be the first person approved by Wellmark!!!!!!!!!!!!

WeekendWarrior, did you ever hear what the announcement was or if it was made? I don't see any changes in the policy on the Wellmark site, but that hasn't necessarily been updated.

I'm really hoping they would have a timely policy change, hehe.

Thanks!

[WeekendWarrior 0]

WeekendWarrior, did you ever hear what the announcement was or if it was made? I don't see any changes in the policy on the Wellmark site, but that hasn't necessarily been updated.

I'm really hoping they would have a timely policy change, hehe.

Thanks!

I haven't heard. I'll try and call the Dr. again next week sometime.

[WeekendWarrior 0]

I see wellmark just changed their policy today.

LINK

Sleeve gastrectomy, as a stand-alone procedure or when combined with a malabsorptive procedure, may be considered medically necessary for patients meeting the above general criteria and one of the following weight criteria:

•BMI ≥ 40 kg/m2 for at least 3 years

Or

•BMI ≥ 35 kg/m2 in conjunction with one of the following:

◦Hypertension requiring medication for at least one year

◦Diabetes mellitus type 2 requiring medication for at least one year

◦Obstructive sleep apnea, confirmed by a sleep study, which does not respond to conservative treatment

◦Documented cardiovascular disease

◦Pulmonary hypertension of obesity

AND one of the following:

•History of transplant, i.e., any solid organ or allogeneic or autologous stem cell

•Chronic corticosteroid use

•Anti-platelet therapy, i.e., aspirin, Plavix® (clopidogrel bisulfate), Ticlid® (ticlopidine hydrochloride), Effient® (prasugrel)

•Inflammatory bowel disease

•History of gastritis or peptic ulcer disease

[journiewilde 0]

I see wellmark just changed their policy today.

WOOHOO! *happydance*

Thank you for letting me know about this. My surgeon's office had decided to wait to apply until this was changed... I'm so glad!

[ShellieB73 0]

What's up with the "AND" stuff.......really......that is extremely frustrating!!!!!!!!!!

[Sweetiepea 0]

I know this is an old post but here is an update on Wellmark BCBS as of March 2011.

http://www.wellmark.com/Provider/MedPoliciesAndAuthorizations/MedicalPolicies/policies/obesity_surgery.aspx

I'm waiting on a decision from them...so we'll see.