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

[Guest guest]

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

> >

> > __________________________________________________

> >