Once and For All, Please Explain Something to me

[Guest guest]

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

__________________________________________________

[Guest guest]

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

>

> __________________________________________________

>