Re: Re: Once and For All, Please Explain Something to me

[Guest guest]

Re: Once and For All, Please Explain Something to

me

> The duodenal switch is really a biliopancratic diversion with sleave

> gastrectomy (i.e. removal of part of the stomach). Biliopancratic

> diversion is not really a gastric or intestinal bypass. It is a re-

> arangement of the small intestines so that bile and food do not mix

> until the end of the small intestine (last 50-125 cm).

Then is it actually redundant to say BPD/DS since it sounds like the BPD

itself is what's switching around the intestines??? Should it really be a

BPD/SG (sleeve gastrectomy)?

alyssa

[Guest guest]

thank you for your reply. I'm printing it out

and putting it in my binder.

Take care,

dee

--- chull1@... wrote:

> Dee,

>

> The gastric bypass involves stapaling off or

> transecting the bulk of

> the stomach and then bringing part of the small

> intestine up to the

> top of the stomach.

>

> The classic intestinal bypass involved disconecting

> 90-95% of your

> intestine and then connecting the remaining portion

> to the duodenum

> (just below the stomach). The long term side

> effects of that surgery

> were severe.

>

> The duodenal switch is really a biliopancratic

> diversion with sleave

> gastrectomy (i.e. removal of part of the stomach).

> Biliopancratic

> diversion is not really a gastric or intestinal

> bypass. It is a re-

> arangement of the small intestines so that bile and

> food do not mix

> until the end of the small intestine (last 50-125

> cm).

>

> There is no CPT code for biliopancreatic diversion

> or the duodenal

> switch. Thus, most surgeons use the code for distal

> gastric bypass

> instead.

>

>

> Hull

>

>

>

> > > > Over 3 weeks ago, Pacificare sent me a letter

> > > saying:

> > > > Intestinal Bypass Surgery is not a covered

> > > benefit " .

> > > >

> > > > Then it went on to say I could appeal it, etc.

> > > >

> > > > When their letter was sent to me, my PCP

> hadn't

> > > yet

> > > > submitted his Letter of Medical Necessity.

> > > Pacificare

> > > > was responding to my phone call where I asked

> for

> > > > proof the DS wasn't covered.

> > > >

> > > > So does that count as a first denial letter?

> I'm

> > > > wondering because if so, I gotta get moving to

> > > send in

> > > > my appeal.

> > > >

> > > > Also, does the RNY have an " intestinal bypass "

> > > > component? I just don't understand. If so, I

> was

> > > > going to use that on my appeal letter.

> > > >

> > > > By the way, I called my PCP and he STILL

> hasn't

> > > sent

> > > > in the Revised Letter of Medical Necessity!

> Three

> > > > weeks!!!!!!!!!! I gave him the sample letter

> -

> > > all he

> > > > has to do is have it copied on his letterhead,

> > > sign it

> > > > and send it in. Jeez! I told the nurse that

> I

> > > was

> > > > running out of time and offered to pick up a

> blank

> > > > letterhead stationary, run home and paste the

> > > sample

>

=== message truncated ===

=====

Dee

Waiting for Ins. Co. Approval

313/Want to be 165

__________________________________________________

[Guest guest]

Dee,

I think is better informed to answer your questions. In fact Just reading

Chris' posts are educational. Yeah Chris!

Re: Re: Once and For All, Please Explain Something to

me

and thank you both for your emails. I

guess I'm getting mixed up because I still have my PCP

involved plus I faxed the " denial " letter to Dr

Rabkin's office last week. If my PCP would get off

the pot and do his letter then he'll be cut out of the

loop and I can continue. This is so ridiculous.

Is there a difference between " intestinal " and

" gastric " ? Pacificare/Marin IPA are saying no to

intestinal bypass not gastric. Does that make sense?

Anyway, thanks again.

dee

--- chull1@... wrote:

> Dee,

>

> I am not sure, but I don't think that their first

> letter counts as a

> denial since it just responds to an inquary

> regarding general

> coverage.

>

> Intestinal bypass sugery usually refers to the old

> JI bypass, and is

> no longer done in the U.S. Both the RNY and the DS

> involve some

> intestinal re-arangement, though in slightly

> different ways. Neither

> procedure is really an " intestinal bypass " . Both

> procedures delay

> the mixing of bile and food, but for the proximal

> RNY it is a minimal

> effect.

>

> The person from pacificare was confused and didn't

> know what the DS

> is. You have to deal with hard CPT codes for them

> to understand.

> Unfortunately their is no CPT code for the DS or

> even for BPD.

>

> There are two major CPT codes in use 43847 refers to

> a " distal

> gastric bypass " and 43846 refers to a " proximal

> gastric bypass " .

> Most DS surgeons use 43847, as this is the closest

> code available at

> this time. The JI bypass has a different code (I

> don't recall what

> it is) and should not be used.

>

> An additional CPT code used for the DS is 43638,

> which is for the

> sleave gastrectomy. This is the code that Aetna

> seems to have

> rejected as " not medically necessary " . Fortunately

> for me, Aetna

> seems to be OK with the " distal gastric bypass code

> (43847) " , so I

> THINK that I am covered for most of the costs.

>

> If you want to know what the coverage will be, you

> must ask about

> codes 43846 and 43847.

>

> Some DS surgeons were reputed to have used 43846 to

> get approval.

> Some have claimed that this is fraud. My view is

> that given the lack

> of a proper code for DS, it is open to

> interpretation.

>

> Technically the DS is not a " gastric bypass " , so

> neither code is

> compleatly accurate.

>

> I think that Dr. Anthone and Dr. Rabkin's choice of

> the term " Distal

> Gastric Bypass with Duodenal Switch " was derived

> from their desire to

> get insurance approval (despite the lack of

> accuracy).

>

> So now I have just confused you even more. It is a

> difficult

> subject, and one that has shades of gray.

>

> Hull

>

>

>

>

>

> > Over 3 weeks ago, Pacificare sent me a letter

> saying:

> > Intestinal Bypass Surgery is not a covered

> benefit " .

> >

> > Then it went on to say I could appeal it, etc.

> >

> > When their letter was sent to me, my PCP hadn't

> yet

> > submitted his Letter of Medical Necessity.

> Pacificare

> > was responding to my phone call where I asked for

> > proof the DS wasn't covered.

> >

> > So does that count as a first denial letter? I'm

> > wondering because if so, I gotta get moving to

> send in

> > my appeal.

> >

> > Also, does the RNY have an " intestinal bypass "

> > component? I just don't understand. If so, I was

> > going to use that on my appeal letter.

> >

> > By the way, I called my PCP and he STILL hasn't

> sent

> > in the Revised Letter of Medical Necessity! Three

> > weeks!!!!!!!!!! I gave him the sample letter -

> all he

> > has to do is have it copied on his letterhead,

> sign it

> > and send it in. Jeez! I told the nurse that I

> was

> > running out of time and offered to pick up a blank

> > letterhead stationary, run home and paste the

> sample

> > letter with my fill ins (which I also gave to

> him!),

> > print it and run it right back for his signature.

> She

> > said he wouldn't allow it. But she's putting the

> file

> > on his chair with a note that I have to pick it up

> > tomorrow.

> >

> > , remember when I first posted, saying my

> doc

> > was going to sign the letter and I would then have

> my

> > surgery? You were so right to slow me down and

> make

> > me realize it's not that easy!!!

> >

> > Thanks,

> >

> >

> > =====

> > Dee

> > Waiting for Ins. Co. Approval

> > 313/Want to be 165

> >

> > __________________________________________________

> >