Re: GOBO, DAWN & STEVE/Unique Code for DS?

May 18, 2001

Teri,

You are absolutely correct in saying that the lack of a specific DS

code is part of the problem. HCFA is responsible for creating these

codes. They are incredibly slow. Since it is not a drug or device(ie

lap band) it does not go through the FDA. At the rate it's going the

lap band will probably have a CPT code befor the DS. The reason?

$$$$MONEY$$$$. The lap band companies are spending tons of money to

get there band approved. They are whooing Dr's (this is what I did

for 10 years for pharmaceutical companies) offering trips to the

Bahamas etc for CME courses all so they can get in a " commercial " for

their product. The problem with a hybrid surgery like the DS is that

there are few people to " push " it. There is no one to finance big

studies etc. The last time NIH did a consensus on the DS was in 1991

and unfortunately HCFA and a lot of the insurance companies wait for

a very favorable nod to our surgery to change. Hopefully the June

ASBS will have some great info on the DS.

Good luck w/ your appeal.

-- In duodenalswitch@y..., " Terri Hassiak " wrote:

> I posted something along this line a week or two ago, but got no

> response. Gobo, this may not help your case right now, but I think

> it would go a long way to helping the BPD/DS become more accepted

as

> a 'gold standard'. The problem is that there is NOT a specific

code

> for the BPD/DS (the sleeve gastrectomy component with retention of

> the pyloric valve and section of the duodenum).

>

> This is actually part of the problem in my situation. My insurance

> is telling me I cannot go out-of-network to have this surgery

because

> there are in-plan surgeons who can provide it. They see it as " all

> gastric bypasses are created equally " because there is no unique

CPT

> code for the BilioPancreatic Diversion with Duodenal Switch.

>

> So here is my question to the list... How does a new CPT code get

> created and accepted by the insurance industry. Does there have to

> be an act of Congress? FDA approval? AMA endorsement? Surely all

> these studies about the long-term success rates of the DS and the

> highly reputed opinions of the ASBS must be worth SOMETHING to this

> end? It seems to me that there currently exist unique codes for

less

> well-proven or successful procedures. How did they get there?

>

> Terri Hassiak

> BMI

>

60http://www.obesityhelp.com/morbidobesity/profile.phtml?N=H980366398

> 5/19/01 surgery date CANCELLED due to " Out-of-Network " Ins. Denial

> email(no spaces): bunsofluff @ hotmail.com

>

> > > Yes, the BPd/DS is the same. Dr. Hess's letter to my

> > insurance company

> > > called my surgery a long limb roux en y (which it is--in

addition

> > to other

> > > things). He then went on to list codes (but didn't name what

> > they are) that

> > > included the reduction of the stomach and other intestinal

> > parts. I had no

> > > problem getting approved (which I am thankful for every day).

> > When my letter

> > > of approval from the insurance company came it said " gastric

> > bypass is a

> > > covered benefit under this patient's plan. " Never did Dr. Hess

> > or the

> > > insurance company use the terms duodenal switch. I think

> > this is partly

> > > because there are no official " codes " for the DS. Doctors have

> > to use other

> > > codes which they feel best represent it. I was in no way going

> > to call the

> > > insurance company and start throwing the DS terminology

> > around. By the way

> > > Dr. Hess's office was amazed at how well my insurance paid

> > on the surgeons'

> > > fees.

> > >

> > > Dawn

> > > Dr. Hess, Bowling Green, OH

> > > BPD/DS

> > > www.duodenalswitch.com

> > > 267 to 165

> > > size 22 to size 10

> > > have made size goal, weight goal may need to be adjusted.

> > > no more high blood pressure, sore feet, or dieting!

May 18, 2001