Guest guest Posted June 25, 2001 Report Share Posted June 25, 2001 Hi ... wrote: Message: 11 Date: Mon, 25 Jun 2001 16:12:38 -0500 From: " Woodward, -GCM " bryan-GCM.woodward@...> Subject: RE: BC BS denying DS 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, &&&&&&&&&&&&&&&&&&&&&& I tried going to the website cited in this message but couldn't get through. Is this a practice that only does the RNY? I find this news interesting because Oregon Health Sciences University's BCBS policy just BEGAN covering WLS (both DS and RNY) in January of this year. AND, Regence BC BS of Idaho just posted on their website about their WLS policies, considering the RNY and DS both acceptable. I am wondering if anyone can point to an official printed statement on the part of BC BS that shows this? ALSO, I notice that Aetna's investigational position on the DS is only listed in a coverage policy bulletin, not in any of their plan books. They say on their website that CPB are " guidelines " and coverage may vary on a case by case basis. Around 10 people on our lists have had Aetna approve their DS while this CPB has been posted. Perhaps on a case by case basis BC BS will do the same. 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 Becky, Try the following web site: http://www.regence.com/trgmedpol/surgery/sur58.html It should be about a 14 page document that I've read now - and am wondering how it applies to my own case. dina RE: BC BS denying DS 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, &&&&&&&&&&&&&&&&&&&&&& I tried going to the website cited in this message but couldn't get through. Is this a practice that only does the RNY? I find this news interesting because Oregon Health Sciences University's BCBS policy just BEGAN covering WLS (both DS and RNY) in January of this year. AND, Regence BC BS of Idaho just posted on their website about their WLS policies, considering the RNY and DS both acceptable. I am wondering if anyone can point to an official printed statement on the part of BC BS that shows this? ALSO, I notice that Aetna's investigational position on the DS is only listed in a coverage policy bulletin, not in any of their plan books. They say on their website that CPB are " guidelines " and coverage may vary on a case by case basis. Around 10 people on our lists have had Aetna approve their DS while this CPB has been posted. Perhaps on a case by case basis BC BS will do the same. 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 26, 2001 Report Share Posted June 26, 2001 I do have an official statement from BC/BS only stating their unsubstantiated claim that the DS is investigational. I believe it to be just another way to save/make money. A question was asked if I am associated with a program that performs the DS, currently my surgeon does not perform the DS. HOWEVER, I have been responsible for the care of over 150 DS patients and believe it to be an appropriate surgery for many people. I hope I have help those who choose to fight for your right to have the DS. Remember in your fight, the American Society for Bariatric Surgery has only condemned two procedures and neither have been the DS. Good luck and let me know if I can help! G. Woodward, MPH, LCEP Live Light, Program Director Gulf Coast Medical Center Biloxi, MS 39531 1- www.gulfcoastmedicalcenter.com RE: BC BS denying DS 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, &&&&&&&&&&&&&&&&&&&&&& I tried going to the website cited in this message but couldn't get through. Is this a practice that only does the RNY? I find this news interesting because Oregon Health Sciences University's BCBS policy just BEGAN covering WLS (both DS and RNY) in January of this year. AND, Regence BC BS of Idaho just posted on their website about their WLS policies, considering the RNY and DS both acceptable. I am wondering if anyone can point to an official printed statement on the part of BC BS that shows this? ALSO, I notice that Aetna's investigational position on the DS is only listed in a coverage policy bulletin, not in any of their plan books. They say on their website that CPB are " guidelines " and coverage may vary on a case by case basis. Around 10 people on our lists have had Aetna approve their DS while this CPB has been posted. Perhaps on a case by case basis BC BS will do the same. 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...
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