Insurance Denied

[fhencherick 0]

I had 6 monthly appts w/ my PCP, 4 appts w nutritionist, 1 appt w/ psych, lost 17 lbs, had appt w/ surgeon who gave order for tests: blood work done, ekg done then had another at a cardiologist which was perfect. then insurance said the sleeve was "experiemental" despite the fact that it received an official diagnosis code of 43775 as of 1/1/10. Now the surgeon will resubmit under gastric bypass. I really wanted the sleeve (don't have sleep apnea, diabetes, heart disease) (do have minor high blood pressue which my PCP believes will disappear very quickly). Why would insurance prefer me to have a more invasive, dangerous procedure when there is a less invasive one to help me achieve optimum health and weight? Does not make sense to me. Has anyone out there had this happen to them???? Felicia in Pennsylvania

[PdxMan 4,292]

My insurance doesn't cover any bariatric procedures, so I was self-pay. I believe you can petition your insurance with the backing of your surgeon and PCP and all the other things supporting VSG no longer being seen as experimental. It takes awhile for things to get across the right person's desk.

[RichardVST 20]

That is crazy. If you have legit insurance, they must cover it. I am sure that they have before. List your carrier and find people on site that have same insurance and have been covered. Also, I would recommend that you review every page of what your doctor submitted and compare it to the list of what the insurance company requires. I did that and found that my file from the MD was extremely disorganized and impossible to follow. And if it was that way for me, you can just imagine the insurance company's eyes glossing over. Everything needs to be laid out and spelled out in very organized simple manner. You need to do this for the MD and make your own case. Call the insurance company, as I did, and ask them to fax you the specific pages that cite their requirements for surgery approval..... Good luck. Don't give up.

[Cabingirl 55]

My surgeon and I agreed the sleeve was the right choice for me, however, my insurance company typically doesn't approve the sleeve for those with a BMI <41. He did agree in our initial appointment to ask this be reconsidered -- as it turned out, the endoscopy and barium X-rays confirmed my horrible GERD. My stomach was pretty trashed and I had a huge paraesophageal hernia that required surgery to remove. No way was I going to do anything as dramatic as a bypass with that diagnosis. Because I was losing so much of my stomach the sleeve was a simple approval by them.

If your surgeon believes as you do that the sleeve is a wise choice, he should be willing to write the letter to the insurance company requesting reconsideration.