Insurance problems

The problem is that the VSG has not had the definitive track record of successful weight loss that RNY has; and that's why U.S. insurance companies, including Medicare, are reluctant to cover this form of surgery.

In my particular carrier's case (Aetna HMO), there was a bulletin about the VSG coverage specifically concerning Medicare coverage (or lack thereof) as a primary reason for their being reluctant to authorize coverage. The exact wording from the bulletin is:

"Sleeve Gastrectomy:
Sleeve gastrectomy is a 70 to 80 percent greater curvature gastrectomy (sleeve resection of the stomach) with continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume (CMS, 2005). It is often the first step in a two-stage procedure when performing RYGB. A decision memorandum from the Centers for Medicare and Medicaid Services (CMS) found that the data supporting open or laparoscopic sleeve gastrectomy are generally sparse and not adequate to draw conclusions. The CMS concluded, therefore, that Obesity Surgery these procedures are not reasonable and necessary for Medicare beneficiaries."
(Source: http://www.aetna.com/cpb/medical/data/100_199/0157.html)

The same bulletin, later on, had a laundry list of medical conditions that needed to be met before they would even consider me a candidate for the VSG in lieu of RNY; primarily in the area of gastrointestinal issues (in my case, it was ulcerative colitus that ruled out RNY, so VSG was my only option if I was to have any kind of weight loss surgery performed). I made sure that my surgeon had a copy of the bulletin as part of the pre-authorization process, and worked with his staff to ensure that the proper codes would be applied to the application as well as a statement of medical condition. I had to do a great deal of homework in the weeks and months leading up to my surgery, so that there would be no issue when it came time to pay.

Happily, Within the last week, I received a statement from the hospital reflecting that the final balance paid in full, so it can happen.

I suggest that you see if there is a bulletin or some document that contains any specific wording about having the VSG done due to medical reasons like I outlined above. If your reason for getting the VSG is because of preference rather than medical need, I suspect until the post-op analysis of a large sample of VSG patients is done, it will be a while before VSG's are an accepted form of weigh-loss surgey along side of the RNY or lap-band.

Hope this helps.

I'm in Australia, so can't comment on the insurance issues in America.
However a friend of mine decided to get a sleeve, but had to change to a bypass when she saw the surgeon due to some other issues.
She filled in the form and got the letters from the doctors and sent them in with her application for release of her superannuation funds for the part of the cost that isn't covered by her heatlh insurance, and just found out last week that she was declined. Apparently the wording in both doctors' letters was not correct - and one of them is the surgeon that does these letters all the time.
So I think Kahuna Lou is correct in saying that you must make sure that you get all the i's dotted and the t's crossed in any insurance application.
Chris

Best of luck with it, Lavender Rose.
Chris

Hi,

Does anyone know if HBF covers the sleeve gastrectomy?
I know Cathy who has done the sleeve with Dr Hairul Ahmad said that her insurance covered most of it and she only had to pay max $600 out of pocket expense.

I am with HBF and thinking of having the sleeve done. But still juggling on it because of the cost.

Thank You

Yools

I'm with HBF and they do cover. But it's the gap you'll need to worry about.

If you ring HBF with the details and the item codes, they will tell you exactly how much they'll pay (and I think the Medicare amount as well). And then they'll send you a document that has it all spelt out for you.

This way, when you look at surgeon's prices, you can see how much you'll be out of pocket. They'll also tell you about the coverage for the hospital and anaesthetist if you have that information.

Kaili.

Thanks Kalli,

I've just called HBF and they said that my health insurance doesn't cover Hospital cover and if I join now there will be a waiting period of 12months @_@

She also strongly suggest to go to the surgeon first and the surgeon can give me the medical#?? whether or not it's covered.

I am going to call the Surgeon's office on Monday ^^

does anyone know how much Americans are reimbused for paying for their own weight loss surgery?

horseapple - I think you can write it down as an itemized item on your taxes if the cost is more than 7% of your income. Ask your CPA though.

thanks El Jefe, I was told today be my tax lady to save everything that it was covered for next year since it is in 2009 feb. well see how that works. Thank again.

I was wanting to know if the sleeve is covered by medicare or classed as elective cosmetic surgery? My workplace gives us health insurance but exclusions are elective cosmetic surgery and items not covered by medicare.
I don't know if it makes any difference but I am in WA.
Anyone who could help I would love to hear from you.