Blue Cross now denying all malabsorptive surgeries

[Guest guest]

It was recently told to me by my MDs office that Blue Cross has just

come down with a decision to halt all authorizations for any of the

" malabsorptive " surgeries. There was one patient who had been

previously authorized, had already started their bowel prep. and the

medical director for the plan called the night before at 5 pm to say

they were " withdrawing authorization. " (!!!) The patient did not

get

their surgery and what their legal options are, I don't know. I

surely do feel for thhem and their family. This happened in

California. This decision by Blue Cross is new this month

(June)Their

reason is that the surgery is " investigational " . As told to me, this

is true for Blue Cross nationwide. The problem is that

there aren't any (or many) RNY surgeons who are publishing studies

and

results of their patients -- wherein the DS and the RNY could then be

scientifically compared. I heard that Dr. Harvey Sugarbaker was

getting close to publishing his RNY studies, but hasn't yet. This is

all information that came out of and was discussed at the ASBS. Is

this the sh*ts or what??

DGB/DS original - 1/11/2000

DS stomach revision - 5/7/2001

Original BMI 51.9

Current 30.8

[Guest guest]

OMG!!! Sweet Jesus, & ph!!! Thank goodness I had my DS 1-15-

01 as I have BC/BS-wellmark (Iowa) and had absolutely NO problems

with receiving authorization. It only took 3 days for approval.

Come again with why they have determined it to be 'investigational'?

What does studies re; the RNY have to do with discontinuing the DS?

If they're getting good results with the DS, why do they have to have

a comparison study??

Colleen - Iowa

BPD/DS 1-15-01

Dr. Buchwald U of MN

-73#

> It was recently told to me by my MDs office that Blue Cross has

just

> come down with a decision to halt all authorizations for any of the

> " malabsorptive " surgeries. There was one patient who had been

> previously authorized, had already started their bowel prep. and

the

> medical director for the plan called the night before at 5 pm to

say

> they were " withdrawing authorization. " (!!!) The patient did not

> get

> their surgery and what their legal options are, I don't know. I

> surely do feel for thhem and their family. This happened in

> California. This decision by Blue Cross is new this month

> (June)Their

> reason is that the surgery is " investigational " . As told to me,

this

> is true for Blue Cross nationwide. The problem is that

> there aren't any (or many) RNY surgeons who are publishing studies

> and

> results of their patients -- wherein the DS and the RNY could then

be

> scientifically compared. I heard that Dr. Harvey Sugarbaker was

> getting close to publishing his RNY studies, but hasn't yet. This

is

> all information that came out of and was discussed at the ASBS. Is

> this the sh*ts or what??

>

>

> DGB/DS original - 1/11/2000

> DS stomach revision - 5/7/2001

> Original BMI 51.9

> Current 30.8

[Guest guest]

That is terrible....I have BC and thankfully it was covered on April 30th....I guess I got mine at just the right time...

Bobbi-jo

[Guest guest]

> It was recently told to me by my MDs office that Blue Cross has

just

> come down with a decision to halt all authorizations for any of the

> " malabsorptive " surgeries.

Does anyone know if this is on the HMO coverage or does it also

include the PPO portion?????

Nick in Sage

[Guest guest]

In a message dated 6/25/01 12:40:22 PM Central Daylight Time,

serenn@... writes:

<<

This is the exact terminology used in my denial letter. I don't know

what I'll do if this exclusion is held. Dr. Booth is appealing, but

if it's nationwide I'm sunk.

I am beginning to feel very bitter about this and about a lot of

things I feel led BCBS to this decision. >>

Stella, sounds like we are in the same boat. I also have Blue Cross Blue

Shield of Alabama thru Bellsouth. Dr. Booth is also my Dr. They denied me for

the DS as " investigational " . He worte an appeal letter and it didn't do any

good. They still denied it. They will cover the RNY and probably the VBG,

but I know those aren't right for me. I am about to hire Walter Lindstrom to

represent me but I wonder if it is futile. Has anyone ever used him to get

this type of decision overturned? I hate to waste my money if it's not going

to do any good.

Cindy W in MS

[Guest guest]

They will cover the RNY

Why will the cover the RNY which is also a malabsorptive surgery but not the DS? Does anyone know if this is true with BlueCross HMO? Does anyone who have received a denial letter belong with an HMO?

gail

[Guest guest]

In a message dated 6/25/01 2:03:46 PM Central Daylight Time, GailFran@...

writes:

<< Why will the cover the RNY which is also a malabsorptive surgery but not

the

DS? >>

They have a LIST of what they consider to be " investigational " procedures and

the BPD/DS is on it. Their info is outdated because the DS has at least a 15

year record of success but they apparently feel that as long as they cover a

gastric bypass procedure then we should be happy to get any kind we can. You

know the majority of the medical profession considers the RNY to be the " gold

standard " of WLS. If that is true, then the DS is the " Platinum Standard " !

Cindy W in MS

[Guest guest]

At 00:460 +0000 6/24/01, jligosky@... wrote:

>reason is that the surgery is " investigational " . As told to me, this

>is true for Blue Cross nationwide. The problem is that

>there aren't any (or many) RNY surgeons who are publishing studies

>and

This is the exact terminology used in my denial letter. I don't know

what I'll do if this exclusion is held. Dr. Booth is appealing, but

if it's nationwide I'm sunk.

I am beginning to feel very bitter about this and about a lot of

things I feel led BCBS to this decision.

--stella

[Guest guest]

Stella, et al

What do you think moved BCBS to this decision? Surely it was not just " one " case

where the obvious problem was a surgical error?!? (This was hinted at in an

earlier post)

-- not holding his breath for his BCBS Insurance approval

Original Message:

-----------------

From: Stella Sloop serenn@...

Date: Mon, 25 Jun 2001 12:32:30 -0500

To: duodenalswitch , jligosky@...

Subject: Re: Blue Cross now denying all malabsorptive surgeries

At 00:460 +0000 6/24/01, jligosky@... wrote:

>reason is that the surgery is " investigational " . As told to me, this

>is true for Blue Cross nationwide. The problem is that

>there aren't any (or many) RNY surgeons who are publishing studies

>and

This is the exact terminology used in my denial letter. I don't know

what I'll do if this exclusion is held. Dr. Booth is appealing, but

if it's nationwide I'm sunk.

I am beginning to feel very bitter about this and about a lot of

things I feel led BCBS to this decision.

--stella

----------------------------------------------------------------------

[Guest guest]

At 13:58 -0400 6/25/01, brinaho@... wrote:

>What do you think moved BCBS to this decision? Surely it was not

>just " one " case where the obvious problem was a surgical error?!?

>(This was hinted at in an earlier post)

the 'one' case I think you're alluding to seems to think that's the case.

--stella

[Guest guest]

I have Regence

BC/BS HMO Oregon – I don’t have a denial letter – but I have had my EOBs sent

to me explaining that my visits to my PCP where the issue was only discussed

will not be paid for. Neither will

any of the referrals (5 of them) she wrote be covered. They simply refuse to become involved

with this issue!

dina

-----Original

Message-----

From: GailFran@...

Sent: Monday, June 25, 2001 11:47

AM

To: duodenalswitch

Subject: Re: Blue

Cross now denying all malabsorptive surgeries

In a message dated 6/25/01 11:06:29 AM Pacific Daylight

Time,

CindyW77@... writes:

They

will cover the RNY

Why will the cover the RNY which is also a malabsorptive surgery but not the

DS? Does anyone know if this is true with BlueCross HMO? Does

anyone who

have received a denial letter belong with an HMO?

gail

----------------------------------------------------------------------

[Guest guest]

Its interesting they call it the gold standard with all the late weight regain.

I think it has to do with the number of drs that do it. Its like

anything...political.

AJ

CindyW77@... wrote:

>In a message dated 6/25/01 2:03:46 PM Central Daylight Time, GailFran@...

>writes:

>

><< Why will the cover the RNY which is also a malabsorptive surgery but not

>the

> DS? >>

>

>They have a LIST of what they consider to be " investigational " procedures and

>the BPD/DS is on it. Their info is outdated because the DS has at least a 15

>year record of success but they apparently feel that as long as they cover a

>gastric bypass procedure then we should be happy to get any kind we can. You

>know the majority of the medical profession considers the RNY to be the " gold

>standard " of WLS. If that is true, then the DS is the " Platinum Standard " !

>

>Cindy W in MS

>

>----------------------------------------------------------------------

>