BCBSIL Duodenal Switch- Has anyone been approved?

[trilla 0]

I have BCBS IL and I'm trying to get approval for a revision from RNY to Duodenal Switch. I am 290lbs with a BMI of 46.8.

On 08/24/2018 my paperwork was submitted. I called my insurance company on 09/10/2018 and I was denied since BCBS IL coverage states that the Duodenal Switch is "not medically necessary for people with a BMI under 50.0". I was told it was in a "pre-determination" status and my surgeon can call for a "peer to peer" with a BCBS IL doctor in which my doctor could argue that it is medically necessary.

Has anyone with BCBS IL been in my situation? Has anyone with BCBS IL gotten a Duodenal Switch and was under 50.0 BMI? Even better has anyone with a failed RNY gotten a revision to a Duodenal Switch and was under 50.0 BMI?

I'm frustrated since I have been working to lose weight and I have lost just enough to be denied. If I were 20lbs heavier I would be approved. Our insurance is so messed up.... I called my doctor and they have an appointment with BCBS IL for the peer to peer on 09/21/2018. I just don't know what my odds are with getting approved. This is so nerve racking.

Thanks in advance.

Edited September 10, 2018 by trilla

[Suwade 25]

I had a SIPS approved at 48.8 BMI thru BCBSIL. But it want easy. My first surgery not a revision.

[trilla 0]

It is specifically related to the duodenal switch procedure.

Congratulations on getting it done.

Edited September 11, 2018 by trilla

[DSquared27 2]

On Sept 6, I was denied surgery due to "not following doctor's orders." My starting weight was around 307 and my weight contract stated I was to get to 296 or under. The last weigh in I did I was 292 and I also did all my clearances. I have AmeriHealth Caritas and when they sent me a denial letter, I had called my doc's office and they appealled it for me and shown them proof I lost the required weight and this resulted in me being approved for Sept 19.

I'm getting a revision done from the gastric sleeve. Apparently my sleeve had stretched. I think you'll be fine. Just keep positive!

[misskim3297 13]

I was approved for DS surgery through BCBSIL but it took multiple submissions. They were very picky about all the paperwork. It was denied the first time bc they couldn't find the cover page for the 45 pages that were faxed over. The bariatric coordinator had to offer/threaten to have the surgeon contact the insurance company. Then it got approved lol My BMI was over 50 so I didn't have that issue. You just have to keep on the insurance company and your surgeon's office. Good luck!

[trilla 0]

Congratulations on your surgery. The peer to peer call is tomorrow afternoon. I wrote a letter outlining my experiences before and after surgery and sent it to my doctor to have for supporting information during the call.

I just hope I'm approved. I feel so powerless.

[mzliz731 6]

I also have BCBS IL and went thru the same thing. I started the process in Aug 2018 to have a revision from the rny(2012) to the DS. Got the denial letter stating I was denied because I showed no proof I had continued doctor supervision. My BMI was also under 50 but the letter made no reference to that being another reason. I actually had to send my copy of the denial letter to the doctor because the insurance was unresponsive to the request they made for their copy!! The doctors also set up a peer to peer meeting and that same day I was approved. My surgery date is set for Jan 7 2019.

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[Frustr8 7,886]

And Congratulations MzLiz, may all go well for YOU!😛

[mzliz731 6]

And Congratulations MzLiz, may all go well for YOU![emoji14]

Thank You!!!!

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