Endoscopic Fundoplication - Insurance Woes

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aciphexo
Regular Member


Date Joined Apr 2011
Total Posts : 377
   Posted 2/9/2012 4:20 PM (GMT -6)   
So, BCBS of MA is refusing to do the pre-authorization or what they call "individual consideration" since this procedure (TIF) [we've submitted as endoscopic fundoplication] is not listed in their codes. They are essentially saying that in my plan - there is "no pre-authorization required" for this procedure.

I don't know what to make of this. If I go ahead with the procedure and they refuse to pay for the surgery afterwards, I can appeal and use the "no preauthorization required" fax and other medical records etc. as part of the appeal.

But I am not sure if I should take this chance. What if they refuse to pay up after?

I will be discussing this with my surgeon and his admins at the hospital - but in the meanwhile, if you all have any comments here, I would surely appreciate them!

Ollie7
New Member


Date Joined Nov 2011
Total Posts : 14
   Posted 2/9/2012 6:39 PM (GMT -6)   
I looked into the TIF a couple of months ago, and luckily I checked my insurance and they had a published statement indicating that the TIF is considered "experimental" and is not covered. I have heard that some offices will bill the TIF with same code as Nissen, but I think you run the risk as surely in the billing details, it will show the TIF device, etc. I personally don't like running the risk of a $10,000 > bill. This is one of the reasons I am still considering the Nissen, as that would likely be covered.

aciphexo
Regular Member


Date Joined Apr 2011
Total Posts : 377
   Posted 2/9/2012 8:05 PM (GMT -6)   
My surgeon is not going to bill this as Nissen. They have specifically called out transoral endoscopic fundoplication and have given details of the procedure in the application and detailed as to why they are doing this and not Nissen etc.

My insurance is not denying or authorizing it since there is no code for this. They are just going by their books. According to them, under my plan I don't need any pre-authorization. So, basically if they deny it after the fact, I do have a good case for the appeals since we have all this documentation from them. However, there is always a chance that they will deny the claim afer the surgery and I won't have the will and money to fight them in the court etc.

According to my surgeon, insurance companies did the same during a brief phase back when laproscopic Nissen was new and they used to do only open Nissens. "Managed Care" has been an eye-opener for me - and I'd believed in it all along - prior to this experience.

Post Edited (PPI-LESS) : 2/9/2012 6:20:49 PM (GMT-7)


Tandem Rider
Regular Member


Date Joined Jun 2011
Total Posts : 122
   Posted 2/9/2012 8:35 PM (GMT -6)   
My Anthem (BSCS in Indiana) paid their part of my TIF. Don't know how it was coded but with so many TIFs being done I would think that MA BSCS would have a code. This health insurance is frustrating.

stkitt
Elite Member


Date Joined Apr 2007
Total Posts : 32602
   Posted 2/10/2012 1:26 PM (GMT -6)   
Transoral incisionless fundoplication is a surgery that usually will be covered by most insurance companies, as it is related to your health and well being. To be on the safe side you could ask your insurance company to send you a letter stating this is a covered procedure under your policy.
 
Good Luck,
Kitt
 
 
~~Kitt~~
Moderator: Anxiety, Osteoarthritis,
GERD/Heartburn and Heart/Cardiovascular Disease.

www.healingwell.com

"only as high as I reach can I grow, only as far as I seek can I go, only as deep as I look can I see, only as much as I dream can I be"

aciphexo
Regular Member


Date Joined Apr 2011
Total Posts : 377
   Posted 2/10/2012 2:13 PM (GMT -6)   
Thanks Kitt.

I was on the phone with the BCBS-MA most of this morning. They've denied the coverage for the TIF surgery. We will be initiating the appeal process.

grapelady62
New Member


Date Joined Nov 2012
Total Posts : 12
   Posted 11/13/2012 5:58 PM (GMT -6)   
Hi I'm a new member and desperate for some suggestions. I am scheduled to have a hernia repair (5 cm. sliding hiatal hernia done with laparoscopy) and a TIF this coming Monday Nov 19th, 2012. I just found out my BCBS of Florda will NOT cover the TIF as it is classified as "experimental". Does anyone have any suggestions on how to appeal this on the phone with BCBS rep? Any buzz words to use etc. My GI doc told me to say that I have significant GERD (very true) and cannot tolerate PPI's, many side effects etc. after 11 yrs of taking them. (very very true)
 I am in a HUGE time crunch here as I have only til Monday to resolve this insurance issue.
My GI does not want me to undergo a Nissen, and much prefers the less invasive, less swelling fewer side effects of the TIF. I have tried alternative meds for the past year to deal with the chronic reflux and gone through the horrible weaning from PPI process with rebound acid for much of the last year, so I am very eager to get this surgery done.
Any suggestions are so appreciated as my out of pocket  "cash" price for the TIF would be $20,000. +, which I cannot afford. Thanks for any help you can offer.

dencha
Forum Moderator


Date Joined Feb 2009
Total Posts : 7181
   Posted 11/13/2012 9:53 PM (GMT -6)   
Hi grapelady,
Welcome to Healing Well!  sorry to hear that you've been struggling with GERD...you're in the right place!  Many here are struggling as well, and there are quite a few who've had surgery. 
 
If I were you I'd put the brakes on the surgery and work out the insurance issues before going forward.  Unless you're independently wealthy, you won't want to take on that type of financial burden.  It appears that you're not alone in finding that your insurance won't cover a TIF procedure (Sorry, PPI-LESS!).
 
I'm curious...why doesn't your doctor want you to have a Nissen?  The Nissen fundoplication is considered the "gold standard" for the treatment of GERD.  It has been done for over 50 years...as an open procedure at first, then laproscopically for the past 15+ years.  I had a Nissen in February 2009, and have been pleased with the results.  FYI, here's my early recovery journal, so you can get an idea of what the recovery from a Nissen might be like (and from what I've read here, what a TIF recovery is like as well...aside from the outside incisions, which are minimal, the recoveries are very much the same.) http://www.healingwell.com/community/default.aspx?f=45&m=2183443
 
While I know your GI doc prefers the TIF procedure, if you need it now, and your insurance won't cover it, your options are limited.  I hope you can convince your insurance company to accept the TIF procedure.  If not, you might want to discuss other options with your doctor.  Good luck!  Hope you get to have the procedure of your choice!
 
Glad you've joined us! 
Best wishes,
Denise
GERD/Heartburn Moderator
Nissen Fundoplication 2/09
Allergy/Asthma

"Whatever you fight, you strengthen, and what you resist, persists.”

“Worry pretends to be necessary but serves no useful purpose”

“Accept - then act. Whatever the present moment contains, accept it as if you had chosen it. Always work with it, not against it.”Eckhart Tolle

aciphexo
Regular Member


Date Joined Apr 2011
Total Posts : 377
   Posted 11/14/2012 12:31 AM (GMT -6)   
Yes, I agree with Denise.

Don't go with TIF if you are paying for it out of your own pocket.

You may also want to read these two threads that covers my situation:

www.healingwell.com/community/default.aspx?f=45&m=2396948

www.healingwell.com/community/default.aspx?f=45&m=2422775

Presently, I am managing my symptoms with 40mg aciphex daily + gaviscon at night (so my name PPI-less is not quite valid anymore - as I am pretty steadily on the PPIs now for the last 3-4 months)

grapelady62
New Member


Date Joined Nov 2012
Total Posts : 12
   Posted 11/14/2012 11:47 AM (GMT -6)   
Thank you Denise. I think you have wise advice to put the brakes on and maybe start all over and look at the Nissen.
I dont know how my surgeon (who may soon not be my surgeon as he does not do nissens) has done at least 25 TIF's , without most insurers covering the "experimental" procedure??? Where are these lucky people? I have read some of the contraindications for nissen on this forum, so maybe they fall into that category. I can't seem to get a clear idea from the office staff as to what to do next, but undergoing 2 separate procedures(hernia repair now and TIF sometime later if and when it is approved) is not something I want to do. It is my understanding that doing a hernia repair without the TIF....would be like having a tree (hernia) crash through your roof, and remove the tree but do nothing for the weakness in the roof(LES)! The frustrations of modern medicine! I know I am lucky to have insurance at all, so I'm very grateful for that....even tho BC is a stinker! 
My daughter has been a medical device rep for 6 years, and actually has been in the OR many times with a doctor who has done many nissens. She has great respect for him, his staff and his successful nissens. The only problem is, he's about a 4 hour drive across the state of Florida. How important is it to stay local? He also requires different testing than the local doc, so I would need more testing.
Thanks for your recovery journal! I learned alot from it and from the others who commented as well.
Like alot of others at the end of the year, I have met my huge deductible...so was hoping for some resolution, but my brakes are on, and soon my turn signal may be too. Thanks, Kathleen
 

bcfromfl
Regular Member


Date Joined Nov 2011
Total Posts : 417
   Posted 11/14/2012 2:43 PM (GMT -6)   
I agree with PPI-LESS and Denise.  Given your financial condition, there really is no "choice" in the matter.
 
I had one of the last TIF procedures performed in Florida, that was at least partially covered by BC/BS.  That was in August of 2011.  What the surgeon did, knowing that there were some issues with coverage, was to separate elements of the procedure into various codes, including a "miscellaneous fundoplication" code.  I don't remember which one it was, but one of his billings (amounting to approximately half of his fees) was denied and he ended up writing it off.  The hospital marked up and then overcharged for the EsophyX device which I disputed, and I ended up having to pay out-of-pocket for a portion of this equipment charge...which was a fraction of what was originally billed to me.
 
I don't understand how you got as far as you did in scheduling the procedure, when BC/BS requires pre-approval for most surgeries?
 
If you have a mild to moderate hiatal hernia, there is no conclusive evidence as of yet that it causes GERD.  Some folks with HH have no reflux, and others without HH do have reflux.  If yours is a paraesophageal hernia, then that is a different matter.  Whatever is done in a HH repair, however, does not impact the LES other than it perhaps allows the LES to flex against a narrower hiatus.  I understand that it is becoming more and more common to do a HH repair with a TIF, but, originally, the TIF was not available to those with HH larger than 2.5cm.  I have a sliding hernia that can reach 2-2.5cm., but it was not repaired.  One endoscopy showed this HH (perhaps because the GI overinflated the stomach), and subsequent endoscopies showed none.  If you fall into this category, I would suggest another endoscopy, and point out beforehand that you wish to avoid the overinflation problem when measuring your HH.  There are many sloppy GIs out there misdiagnosing HH!
 
What most surgeons do NOT do with respect to recommending the various GERD surgeries, is to separate their patients into symptom categories before making recommendations.  The reason this is important is that a procedure such as the TIF is considered a "bridge" procedure (between medication and laparoscopic surgery), and has a relatively low resolution rate for atypical symptoms.  If you have mild to moderate heartburn, or perhaps occasional "volume" reflux, it may work as well as a Nissen.  Complete airway symptom resolution is unfortunately rare with the TIF.
 
I don't know where you are located in Florida, but Dr. Rosemurgy in Tampa is perhaps one of the most experienced Nissen surgeons in the country.  You may also want to investigate the Hill-Nissen repair, done in Albany, GA by Dr. Bagnato.
 
You mentioned testing, and that your current surgeon didn't require the tests that someone else does.  This concerns me, as fundoplication surgery, however it is done, requires a complete evaluation of the involved organs and tissues.  Manometry, barium swallow, biopsies, and pH studies are, at a minimum, requirements.
 
-Bruce

Post Edited (bcfromfl) : 11/14/2012 1:05:00 PM (GMT-7)


grapelady62
New Member


Date Joined Nov 2012
Total Posts : 12
   Posted 11/15/2012 7:14 PM (GMT -6)   
Thank you Bruce for your extremely informative post! I took notes and copied your post to use as ammo with my Dr.'s office but it will not be necessary. Unbelievably, someone has moved moutains and my surgery is back on for Monday Nov. 19! I am elated and grateful beyond words! I will get to the bottom of how this happened, and post after the "hybrid" procedure on Monday. They will repair the 5cm sliding hernia laparascopically, and then do the TIF. The surgery coordinater said that these "denials" of coverage for TIF keep happening so my GI, general surgeon and the hospital got together with a call to BCBS...and discussed the procedure, its efficacy and the proper code for the combination...I guess everybody gave in a little, and I got approved. Having been on various PPI's every day from 2000-2011 with plenty of nasty side effects, I finally took the last one Nov28, 2011. Tried alternative methods with small successes....but mostly miserable with acid rebound, early 3:00pm dinners on the days I could eat, sitting up til 4:00am, only left side sleeping on a raised headed bed, and an esophagus that felt like a fiery tube. So I am very very happy to be moving forward and have regular meal times with my husband, the most patient man in the world!
(maybe some red wine again?) I will let you know when I know HOW this happened....maybe BCBS is revising their coding to allow for the "hybrid". We can all hope. I am very grateful to all 3 of you who responded to my post. You are like beams of light when things looked darkest! thanks, Kathleen

grapelady62
New Member


Date Joined Nov 2012
Total Posts : 12
   Posted 12/3/2012 9:43 PM (GMT -6)   
Well the bottom line is that my HH repair and TIF are done. I am 2 weeks post surgery and feeling great! Thanks to my doctor, the hospital and BCBS the correct coding was finally figured out and the procedures were approved. I am forever grateful.
Does anyone have any tips on the post surgery 6 wk liquid diet? I have the normal protein shakes, carnation instant breakfast...jello, pudding, yogurt etc. and now week 3...Oatmeal!I am also blending the heck out of some steamed or nuked veggies and inserting them into chicken broth. Did I miss anything? One thing that does concern me is the unrealistic and unearned weight loss. I'm afraid that when the 6 wks are up, and you start to introduce real small bites of real food slowly....my body might latch on to every calorie! While my husband and I eat a very very healthy diet, it still worries me. Did anyone else cough alot after the TIF. I did before but usually associated with an acid attack. My doctor is very laid back about the effects of coughing etc. on his sutures and mesh(to repair the hernia) and H fasteners to complete the fundoplication. Anyone else have these concerns? Thanks ahead for any suggestions. Kathleen
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