Major Bump In The Road

[bella143 8]

Oh my gosh I'm sorry! Which insurance do you have? Why did they deny you?

[Wheetsin 714]

Lots of things kinda weird about this. Start with the CPT codes for all three procedures mentioned. I think they are:

• VSG: 43843
  
• Band: 43770
  
• RNY: 43644
  

Then call the customer service # of your insurance provider and ask the person who answers to look through your plan and tell you the BMI requirements for each procedure. I advise doing this to start because usually the BMI requirements are the same (per provider) for all three procedures, and are based on FDA guidelines. I think for all three, it's currently a BMi of 40+, or a BMI of at least 35 with 1+ (or 2+) comorbidities. When they do require higher BMI, it's usually because they aren't yet recognizing the sleeve as a standalone procedure. Do you know if your insurance covers VSG as a standalone bariatric procedure?

The other part that's weird is that your surgeon's office, I would hope, would have obtained the insurance requirements and informed you up front if your BMI was sufficient or not. You should not be finding out 6 months later that you never met the criteria to begin with. Or are they considering your weightloss during the last 6 months to be the loss that made you now ineligible? What was your BMI then & now?

I was initially denied for the sleeve. I wrote my own appeal, my surgeon's office submitted it, and the procedure was approved about 3 days later. Long story short I ended up having to start over with a completely different provider, totally back to square 1. I just made sure they didn't have a chance to deny me this time.

...I found out I don’t 'meet the criteria'. Apparently I have to have a BMI of 50 or more. Mind you I went through 6 months of hell & even lost 15lbs in the process. Now to be told I'm not eligible. My heart is broken. Insurance said I can have gastric bypass (no thanks) or the band (Not sure).

[Wheetsin 714]

Oh, and when a procedure is denied because a BMI is too low, but is still inthe range of the FDA recommendations, denials are most often overturned if you can prove significant comorbidities. I don't mean "regular" comorbidities like joint pain/arthritis, I mean cardiovascular & respiratory comorbidities that can kill you. If you can substantiate not just "medically necessary" but "going to die without" (or more accurately, going to cost you a heckuva lot more without) insurance companies are more flexible in their BMI requirements, usually.

[KatieOkieDokie 171]

I am so sorry to hear this I can't even imagine how that would feel! I am currently trying to find funding, and come up with ways to pay for my surgery (no insurance) but I honestly think it would be more disappointing to have insurance go through every test, appointment, and pre-op diet, with a set date and be turned denied. That would just be a crushing blow, and it's hard not to get disappointed and discouraged I know, but to have it so close and then taken away would be a lot to handle. I'm sorry.

And I think yecats said it best!

For some reason it just was not suppose to be right then but do not get discouraged, you will see in the future looking back how it is in the best timing. Keep believing!!!!!!

[Dooter 1,457]

:( :( :( I'm so sorry!!

[IowaAndy 95]

Sorry for all of your disappointment but hopefully this will all be taken care of and soon. Please do not let them talk you into having bypass or the lapband. I had a lapband and it was nothing but troulble....Fills and then taking Fluid out.....non stop vomiting. I was never so glad as to when I had it removed and had the sleeve. I love my sleeve and wish it had been an option for me when I had the band several years ago. I would have this done again anytime. Keep up the fight and file that appeal. Never give up.

[aldmb2 24]

Thanks for all the encouraging words. I have one minor issue also. I dont really have any medical conditions. I dont have diabetes, or HBP. Nothing. I'm just an overweight 29yr old. I'm having a hard time pleading my case

[teambrown4 19]

I went through almost the same thing with Cigna! Well it was 3 weeks out and I hadn't fasted yet tho! I was crushed and cried that entire day and then said... No this is really important and I jut gotta folloow through.

So I kept my surgery date, used my savings and 20k & 3 weeka later I had my surgery on 2/13/12.

I'm not done writing and submitting info and bills to Cigna, but I just had to get through it!

I wih you lots of luck! if you have the time then email & call them daily! Submit statistics for the long term Health issues and pictures and whatever u can gather to get ONE PERSON to look at u and make te Change!

To approve band and not sleeve makes no sense! State the fact that there's more long term office visits with the band for the constant maintaince and the slippage rates and so on! It's ridiculous to approve any if not all!

Wish u luck

[Ms skinniness 3,003]

this is so frustrating. I was told by Kaiser that I had to loose a certain percentage of my weight before given a referral for this procedure. I lost weight and when I was 3 week away from surgery, the surgeon told me my BMI was too low for insurance to cover it. WTF! I tried everything I could to gain weight and couldn't. Then I went in and talked with the surgeon and told her I was taking Lisnipril to protect my kidney's because I have diabetes. She went and checked the records and then ok'd it. I was so angry and frustrated, and worried about being turned away at the morning of the surgery. It was horrible. I'm so sorry your having this problem. It sucks!

The doc can get it over turned, he just has to take the time to speak with the insurance company, in which he should of done this months ago!. ARGGGG! Good luck and I cant' wait to see you at the LOSER'S BENCH!

[mnbsleeve 87]

I'm so sorry for all this! I don't have much to contribute but wanted to send you and the others here with similar issues my thoughts and wishes for a quick resolution so you can move on. Please don't lose hope!!! We are all pulling for you!!!

[Catracks 865]

A BMI of 50????!!!!!!! 40 is already morbidly obese. If I had a BMI of 50, I wouldn't be able to move. Insurance companies are just nuts sometimes.

[aldmb2 24]

Yes 50!! they want me to weigh over 300lbs before they approve it. I'm awaiting my denial letter to get my appeal ready for them. I was initially going to get the band, but after speaking with my surgeon & doing more research I decided the sleeve was the way to go. I believe somewhere along the lines my Dr. office failed to investigate my approval for the sleeve. They failed to check. They dropped the ball.

[Lisa821 29]

I am sorry that you are going through this. All that prep just to get that kind of news. I went through something similar. I was lead to believe that I would be approved as well but after four months of jumping through hoops, missed time at work for appts and high hopes, I was denied. In the end my insurance company denied payment on those appts, psych eval and dietician appts. Therefore about $900 in bills that I'm still paying on. I figure they will get their money slowly since they were so misleading. However, last November I decided to go to Mexico and pay for the VSG. I'm glad I did. I'm down 54 pounds and I'm very happy with my results. It would have been nice not to have an extra $900 to pay though. I've accepted it and shifted my focus to getting healthy with my new sleeve. I don't have back pain anymore, I sleep better, I breathe better and don't have depression like I did before. Hang in there and go through the appeals process. Some insurance companies just deny everyone's request and make them fight for it as a policy. Keep posting, we're here for you.

[Iliana82 84]

Oh my how frustrating! Keep your head up! It will all work out!!!

[Wheetsin 714]

I don't know of any insurance companies that automatically deny, just to make you fight (worked for a very large insurance company for years, and do private consulting with a large handful of others). It may seem like that's what they're doing, but they wouldn't be allowed to be in business if it were the case. It does depend on the MRO reviewing your claim They try to be consistent, but absolutely "Jack" will accept some things that "Jill" will not, and vice versa. There are some cases of absolute consensus, but there's an awful lot of gray area between those points of agreement.

So (OP) do I understand correctly that you were denied for sleeve because your BMI wasn't over 50, but you were approved for either the band or the RNY?

Have you taken my advice earlier (if not it's fine) and called your insurance company to check on approval of the sleeve as a standalone procedure, or the BMI requirements for the procedures they were willing to cover? What insurance company do you have, if you're comfortable sharing?