Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 In a message dated 6/25/01 3:33:11 PM Central Daylight Time, beckeye_58@... writes: << Does anyone have any knowledge (printed statements, etc) that BC/BS is actually doing this as a nationwide thing and not just in CA? I haven't heard anything from other states/groups, etc. BC/BS of OR doesn't cover any WLS so that's rather academic, but what about other states who've been covering? >> I know there are some BCBS companies that do not cover ANY type of WLS. I guess I should feel fortunate that mine does at least cover some of them, but my Dr. said the RNY for me (BMI=54) would virtually be " malpractice " . Cindy W in MS Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 In a message dated 6/25/01 4:45:55 PM Central Daylight Time, terjer1976@... writes: << Perhaps the root of the problem is because the DS is more expensive and they feel that the extra cost is not justified since both surgeries are malabsorptive. Just a thought. >> I'm sure that probably is the basis for their reasoning but the differences in these 2 procedures is so much greater than price. They need to consider the long term effects of these surgeries for the super morbidly obese and recognize that the extra cost is justified. Unfortunately thier decisions seem to be more about economics than helping their customers (the patients). Cindy W in MS Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 In a message dated 06/25/2001 4:21:13 PM Central Daylight Time, bryan-GCM.woodward@... writes: << Gastric Bypass code to obtain insurance approval for the DS. >> But there is no code for the DS. Often the code that is often for the distal RNY works. It is a code that is for wls with a malabsorbtive component. BC/BS approved and paid for mine and they also went over the operative report. Dawn--Chicago metro--south Dr. Hess, Bowling Green, OH BPD/DS www.duodenalswitch.com 267 to 165 5'4 " 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! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 The denial of the DS is nation wide through BC/BS and has been for over a year. Some state managed BC/BS policies may have missed the nation wide policy exclusion and may have covered it when the policy managers were actually suppose to deny the procedure. In addition, there are some surgeons who inappropriately use the Gastric Bypass code to obtain insurance approval for the DS. The reason for concern over this action is that if BC/BS did an audit of your surgery or the surgeon, they may be able to deny payment - leaving you financially responsible for the bill. I have not heard of this actually happening, but I would not put it passed the insurance company. Why are they denying coverage? The answer- under a physician review, BC/BS determined that the DS was investigational. They have concluded this after reviewing classic BPD research articles and the lack of multiple published BPD/DS papers. Hope this helps, G. Woodward, MPH, LCEP Live Light, Program Director Gulf Coast Medical Center Biloxi, MS 39531 1- www.gulfcoastmedicalcenter.com BC BS denying DS Hi all. Does anyone have any knowledge (printed statements, etc) that BC/BS is actually doing this as a nationwide thing and not just in CA? I haven't heard anything from other states/groups, etc. BC/BS of OR doesn't cover any WLS so that's rather academic, but what about other states who've been covering? I totally doubt this is based on one case. The " malabsorptive-ness " of the DS doesn't really have anything to do with Deb if that's the one people are referring to. I'd be more accepting if they were now denying malabsorptive surgery based on a few dozen who've died due to malnutrition. blessings~ becki ===== Becki, near Portland, OR BMI 50-ish, age 42 pre-op DS. hoping to get approval through Aetna Traditional Choice (fighting 'investigational' denial) Consulted with Dr. on 3-13-01 psych ok, nutrition ok, beckeye_58@... __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 From what I understand, RNY has also is a " malabsorptive " surgery. Anytime they " re-route your plumbing " it is to cause malabsorption. Have I mis-understood? Perhaps the root of the problem is because the DS is more expensive and they feel that the extra cost is not justified since both surgeries are malabsorptive. Just a thought. Jerry, Pre-op, Dr. Booth, MS > >Reply-To: duodenalswitch >To: duodenalswitch >Subject: BC BS denying DS >Date: Mon, 25 Jun 2001 13:18:10 -0700 (PDT) > >Hi all. Does anyone have any knowledge (printed >statements, etc) that BC/BS is actually doing this as >a nationwide thing and not just in CA? I haven't heard >anything from other states/groups, etc. BC/BS of OR >doesn't cover any WLS so that's rather academic, but >what about other states who've been covering? > >I totally doubt this is based on one case. The > " malabsorptive-ness " of the DS doesn't really have >anything to do with Deb if that's the one people are >referring to. I'd be more accepting if they were now >denying malabsorptive surgery based on a few dozen >who've died due to malnutrition. > >blessings~ > >becki > >===== >Becki, near Portland, OR >BMI 50-ish, age 42 >pre-op DS. hoping to get approval >through Aetna Traditional Choice >(fighting 'investigational' denial) >Consulted with Dr. on 3-13-01 >psych ok, nutrition ok, beckeye_58@... > >__________________________________________________ > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 My insurance is not through BC however, it does state in the policy that IF they cover something and pay out any money and later decide that it was covered in error...they expect to get their money back from you!! Insurance companies have all sorts of protective statements!! Does " Live Light " do the DS surgery? I thought that the only one in MS was Dr. Booth's group. Also, I was under the impression that there is no code for DS alone...that is is a gastric bypass. Just wondering! Jerry, Pre-op, Dr. Booth,MS (waiting on insurance... what else??!!) > >Reply-To: duodenalswitch >To: duodenalswitch >Subject: RE: BC BS denying DS >Date: Mon, 25 Jun 2001 16:12:38 -0500 > >The denial of the DS is nation wide through BC/BS and has been for over a >year. > >Some state managed BC/BS policies may have missed the nation wide policy >exclusion and may have covered it when the policy managers were actually >suppose to deny the procedure. In addition, there are some surgeons who >inappropriately use the Gastric Bypass code to obtain insurance approval >for >the DS. The reason for concern over this action is that if BC/BS did an >audit of your surgery or the surgeon, they may be able to deny payment - >leaving you financially responsible for the bill. I have not heard of this >actually happening, but I would not put it passed the insurance company. > >Why are they denying coverage? The answer- under a physician review, BC/BS >determined that the DS was investigational. They have concluded this after >reviewing classic BPD research articles and the lack of multiple published >BPD/DS papers. > >Hope this helps, > > > > G. Woodward, MPH, LCEP >Live Light, Program Director >Gulf Coast Medical Center >Biloxi, MS 39531 >1- >www.gulfcoastmedicalcenter.com > > > BC BS denying DS > > >Hi all. Does anyone have any knowledge (printed >statements, etc) that BC/BS is actually doing this as >a nationwide thing and not just in CA? I haven't heard >anything from other states/groups, etc. BC/BS of OR >doesn't cover any WLS so that's rather academic, but >what about other states who've been covering? > >I totally doubt this is based on one case. The > " malabsorptive-ness " of the DS doesn't really have >anything to do with Deb if that's the one people are >referring to. I'd be more accepting if they were now >denying malabsorptive surgery based on a few dozen >who've died due to malnutrition. > >blessings~ > >becki > >===== >Becki, near Portland, OR >BMI 50-ish, age 42 >pre-op DS. hoping to get approval >through Aetna Traditional Choice >(fighting 'investigational' denial) >Consulted with Dr. on 3-13-01 >psych ok, nutrition ok, beckeye_58@... > >__________________________________________________ > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 Amen,Sister!! I, too, have done my research and feel that DS in the only way to go! I have seen Dr. Booth and have been waiting and WADING through insurance " garbage " ever since(since first week of Feb.) No denial yet but no I will be fighting their " criteria " and out of network coverage. The criteria I do not meet. I don't feel that anyone who has been MO for over 20 years and been through the diet game would meet their criteria!! The criteria is for someone who just woke up and found themselves fat one morning!! It is all about the bottom dollar with insurance companies....but, alot of businesses are getting that way!! Keep up the fight! Jerry, Pre-op, Dr. Booth, MS (Hopefully) >From: CindyW77@... >Reply-To: duodenalswitch >To: duodenalswitch >Subject: Re: BC BS denying DS >Date: Mon, 25 Jun 2001 18:02:38 EDT > >In a message dated 6/25/01 4:45:55 PM Central Daylight Time, >terjer1976@... writes: > ><< Perhaps the root of the problem is because the DS is more > expensive and they feel that the extra cost is not justified since both > surgeries are malabsorptive. Just a thought. >> > >I'm sure that probably is the basis for their reasoning but the differences >in these 2 procedures is so much greater than price. They need to consider >the long term effects of these surgeries for the super morbidly obese and >recognize that the extra cost is justified. Unfortunately thier decisions >seem to be more about economics than helping their customers (the >patients). > >Cindy W in MS > >---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 I was told by a BCBS Rep that it depends on the individual patient. --- CindyW77@... wrote: > In a message dated 6/25/01 4:45:55 PM Central > Daylight Time, > terjer1976@... writes: > > << Perhaps the root of the problem is because the DS > is more > expensive and they feel that the extra cost is not > justified since both > surgeries are malabsorptive. Just a thought. >> > > I'm sure that probably is the basis for their > reasoning but the differences > in these 2 procedures is so much greater than price. > They need to consider > the long term effects of these surgeries for the > super morbidly obese and > recognize that the extra cost is justified. > Unfortunately thier decisions > seem to be more about economics than helping their > customers (the patients). > > Cindy W in MS > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 Cindy, If you mean it wouldn't be enough, we are sailing in the same boat. I have no thyroid and my Dr. pretty much told me BPD was the only way to go to get rid of the weight. My BMI is 58. I know how you feel. I have a feeling it is all in how it is worded and each individual case is different. --- CindyW77@... wrote: > In a message dated 6/25/01 3:33:11 PM Central > Daylight Time, > beckeye_58@... writes: > > << Does anyone have any knowledge (printed > statements, etc) that BC/BS is actually doing this > as > a nationwide thing and not just in CA? I haven't > heard > anything from other states/groups, etc. BC/BS of > OR > doesn't cover any WLS so that's rather academic, > but > what about other states who've been covering? >> > > > I know there are some BCBS companies that do not > cover ANY type of WLS. I > guess I should feel fortunate that mine does at > least cover some of them, but > my Dr. said the RNY for me (BMI=54) would virtually > be " malpractice " . > > Cindy W in MS > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 Just FYI....this appears to be a more national trend than simply the locals in California....we're starting to see alot more of this type of denial from all over - and not just with BCBS members..... Walter Lindstrom, Jr., Esquire Obesity Law & Advocacy Center www.obesitylaw.com 2939 Alta View Drive, Suite O-360 San Diego, CA 92139 Tel: Fax: Re: BC BS denying DS > Cindy, > If you mean it wouldn't be enough, we are sailing in > the same boat. I have no thyroid and my Dr. pretty > much told me BPD was the only way to go to get rid of > the weight. My BMI is 58. I know how you feel. I have > a feeling it is all in how it is worded and each > individual case is different. > > --- CindyW77@... wrote: > > In a message dated 6/25/01 3:33:11 PM Central > > Daylight Time, > > beckeye_58@... writes: > > > > << Does anyone have any knowledge (printed > > statements, etc) that BC/BS is actually doing this > > as > > a nationwide thing and not just in CA? I haven't > > heard > > anything from other states/groups, etc. BC/BS of > > OR > > doesn't cover any WLS so that's rather academic, > > but > > what about other states who've been covering? >> > > > > > > I know there are some BCBS companies that do not > > cover ANY type of WLS. I > > guess I should feel fortunate that mine does at > > least cover some of them, but > > my Dr. said the RNY for me (BMI=54) would virtually > > be " malpractice " . > > > > Cindy W in MS > > > > > ---------------------------------------------------------------------- > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 If this is true, it is interesting to me. Blue Cross/Blue Shield PPO (of Massachussets) approved my DS in April. Of course, I don't know if they've followed through and paid for it yet....and I don't want to even think about it! Anyway, they didn't deny it, so I'm not sure where the info that they've been denying it for a year is coming from. Dawna Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 26, 2001 Report Share Posted June 26, 2001 The Dr. I was planning to have do my surgery here in Maine, Dr. Aslam told a group of us at our first consult, (every one else was there for RNY) That B/C was now denying, and he has decided to put DS surgey on hold for a least a year. So I have canceled my appt. with him and for my gallbladder scan. I haven't officially gotten a denial because if he's not going to do the surgey then there is nothing t deny. As he does the RNY I am assuming that they will pay for that visit becasue I was just there for a cansult for wls, I don't think it will be specified which one, Darlene from Maine Darlene Pre-op BMI 49 waiting ????? whats up with BC/BC????? BC BS denying DS Hi all. Does anyone have any knowledge (printedstatements, etc) that BC/BS is actually doing this asa nationwide thing and not just in CA? I haven't heardanything from other states/groups, etc. BC/BS of ORdoesn't cover any WLS so that's rather academic, butwhat about other states who've been covering?I totally doubt this is based on one case. The"malabsorptive-ness" of the DS doesn't really haveanything to do with Deb if that's the one people arereferring to. I'd be more accepting if they were nowdenying malabsorptive surgery based on a few dozenwho've died due to malnutrition.blessings~becki=====Becki, near Portland, ORBMI 50-ish, age 42pre-op DS. hoping to get approval through Aetna Traditional Choice (fighting 'investigational' denial)Consulted with Dr. on 3-13-01psych ok, nutrition ok, beckeye_58@...__________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 26, 2001 Report Share Posted June 26, 2001 Why would they start denying , when they have been paying? have we all been missing something? Are there more problems that we aren't hearing about? darlene from Maine Darlene Pre-op BMI 49 waiting ????? whats up with BC/BC????? Just FYI....this appears to be a more national trend than simply the localsin California....we're starting to see alot more of this type of denial fromall over - and not just with BCBS members.....Walter Lindstrom, Jr., EsquireObesity Law & Advocacy Centerwww.obesitylaw.com2939 Alta View Drive, Suite O-360San Diego, CA 92139Tel: Fax: Quote Link to comment Share on other sites More sharing options...
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