Expert: John Pilcher, MD - 8/27/2007

Question
I am a 43 year old that is 6 years post op.  I had no problem with the original surgery.  I started @ 250 pounds and lost down to 118.  I am now 175 and having terrible pains associated with a fistual or possible ulcer.  My surgeon feels that the fistula may have opened up my original stomach thus allowing me to gain weight back.  He seems to be of the opinion that getting approval for a revisional may be difficult.  My question is what medical information do I need to feed the doctors office to get the revisonal covered for medcial necessity.  Surely this can not be as difficult as he is making it.  If a surgery is having complications why would this be so difficult to be medically necessary in a persons well being?

Answer
Teri,
This is a really challenging situation, from both a medical standpoint and from an administrative/insurance standpoint.

It's hard for me to give you advice about how your surgeon could get around the barriers placed by the insurance company, because the best way to get you the care you need depends on the specific insurance company and also on how it is administered.

I think your best bet is to take your case to the insurance company directly, since you will be a more effective advocate for yourself than the (probably overworked) staff in your surgeon's office.  First, ask the surgeon's office what code matches up with the procedure that he/she plans for you - I would guess it will be 43848, which is a revision gastric bypass.  Next, call the insurance company and work with them to find out what information they need to pre-authorize (approve) that surgical procedure for treatment of your problem (diagnosis code for fistula is 569.81, and for gastro-jejunal ulcer is 534.30).

You might also work with the insurance company and the surgeon on a related surgical procedure code for ulcer treatment, such as 43633, which might be properly used to describe the surgery planned for you.  If your surgeon believes that code fits your required revision procedure then it is likely to work for the insurance company as well.

Best of luck!
Dr JP