Once per lifetime max on anthem bcbs

[shiannajohnson 2]

Hello!

Has anyone ever been able to get a conversion surgery approved on an insurance that has a "once per lifetime max" on bariatric surgery? I had the sleeve in 2018 and now suffer from severe GERD/acid reflux. No meds are taking care of it. The insurance has denied the claim once already because its not "medically necessary". Anyone know of tips or tricks?

[liveaboard15 1,294]

Probably not going to get around that. I have thought about that too since my state excludes all bariatric surgery. and i am hoping i never have heart burn issues but if i ever needed a revision to bypass my plan would be to move to another state temporarily, Set up residency, Get insurance, Get the procedure done and move back. Yea lots of work but $20K+ for revision is too high for most people to pay out of pocket. I paid $19K for my sleeve out of pocket andi am out of money lol

[RickM 1,753]

This is something that should be covered as a complication from an previously covered procedure, rather than a second WLS; it may takes jumping through some hoops to get there, but you should (eventually) get it. This likely got an automatic denial as claiming a second WLS and needs to be appealed, first through the BCBS internal process, and then, failing that, through your state insurance regulator. The first appeal step will usually involve a peer to peer review, where your surgeon talks to their staff doctor to explain the medical necessity on a doc to doc basis.. Once it is apparent the ramifications of your situation (and their liability for not covering it...) it should go through. Your doc should be able to discuss with them what steps have already been taken to resolver the (medical) problem - what meds have been tried and failed, what tests have been done, what your prognosis is without surgical intervention, etc.

Good luck

again, it should go through, they just need to be slapped around a bit to realize their obligation.

Another possibility is that your surgeon's office coded it as a standard RNY, and there's a different code to use as a GERD treatment (the basic RNY procedure is used for several different maladies beyond its basic WLS function, but it goes by a different name (and code).

[liveaboard15 1,294]

3 hours ago, RickM said:

This is something that should be covered as a complication from an previously covered procedure, rather than a second WLS; it may takes jumping through some hoops to get there, but you should (eventually) get it. This likely got an automatic denial as claiming a second WLS and needs to be appealed, first through the BCBS internal process, and then, failing that, through your state insurance regulator. The first appeal step will usually involve a peer to peer review, where your surgeon talks to their staff doctor to explain the medical necessity on a doc to doc basis.. Once it is apparent the ramifications of your situation (and their liability for not covering it...) it should go through. Your doc should be able to discuss with them what steps have already been taken to resolver the (medical) problem - what meds have been tried and failed, what tests have been done, what your prognosis is without surgical intervention, etc.

Good luck

again, it should go through, they just need to be slapped around a bit to realize their obligation.

Another possibility is that your surgeon's office coded it as a standard RNY, and there's a different code to use as a GERD treatment (the basic RNY procedure is used for several different maladies beyond its basic WLS function, but it goes by a different name (and code).

You know i tried something similar. So weight loss surgery is excluded for me. So i spoke to the insurance to see if i was diagnosed with severe gerd, would they cover gastric bypass surgery since its basically a cure to it. They straight up told me no. I was like of course thats just my insurance.

[RickM 1,753]

14 hours ago, liveaboard15 said:

You know i tried something similar. So weight loss surgery is excluded for me. So i spoke to the insurance to see if i was diagnosed with severe gerd, would they cover gastric bypass surgery since its basically a cure to it. They straight up told me no. I was like of course thats just my insurance.

I can certainly understand that, as they tend to be familiar with different dodges used to get around their exclusions. There are a number of procedures that are used to treat GERD, depending upon what the cause is. Fixing a hiatal hernia, for instance, doesn't require a bypass to accomplish, though such repairs are commonly performed in conjunction with WLS, either a sleeve or pouch type.

When I had my VSG, it was just starting to be routinely approved by US insurance companies -some did, others still called it "investigational", As a legacy of that, insurance commonly excluded the 2 step DS (as the DS uses that sleeve as its basis, in extreme cases they would do a VSG first, and then once the patient had lost enough weight to undergo the longer switch part they would do that as a second procedure - that was the origins of the VSG, as some found that they lost enough on just the VSG that they didn't need to go through with the second part. Insurance got wise to the dodge of getting approval for the DS but only doing the first VSG part, so they blocked that approach. Of course, for those who really needed to go that route, it was still available but they needed to jump through more hoops to get there.

Had your surgeon approached them, it might have flown (assuming that it was a justifiable approach for your GERD, as they would not be asking for an RNY WLS, but using different terms and codes. The same basic procedure (it's called a Billroth II) is used for treating several different maladies, and the rules and codes are different for each. The sizes of limbs and the pouch are different for an RNYGB WLS than they would be for a partial gastrectomy used in treating gastric cancer or gastroparesis, though they are the same basic procedures.