Tricare denying gastric bypass for 12yo with rare cond.

[EVT1]

I am sure they can find a way to help this girl out, but this shows another weakness in our health care system- which applies across the board public and private- medical decision making by non-doctors based on strict (bad) policy.

     Surgery to remove a brain tumor two years ago has left a 12-year-old Texas girl with a heartbreaking condition that makes her gain massive amounts of weight — even though her body thinks it’s starving.

     Doctors say a gastric bypass operation is the only thing that can help Alexis Shapiro, who is 4-foot-7 and weighs 198 pounds. But the U.S. military, which provides her family’s health insurance, says it won’t pay for the $50,000 weight-loss procedure because she’s too young. 

    “Our reviewers have denied your request for Roux-En-Y Gastric Bypass,” reads the rejection notice sent this month.

     In just the past three months, Alexis was hospitalized for a kidney infection and developed Type 2 diabetes that requires nightly insulin injections, both related to her growing girth.

     But a spokesman for TRICARE and Humana Military, which provides insurance coverage for Alexis’ father, Air Force veteran Ian Shapiro, said their rules are clear. Gastric bypass and other weight-loss surgeries may be covered, but only if the patient is 18 or has achieved full bone growth.

     “In general, our Managed Care Support Contractors are required to approve or deny coverage based on TRICARE policy,” spokesman Austin Camacho said in an email to NBC News. “We have an appeals process in place specifically designed to give our medical professionals the opportunity to examine the details of any special cases when coverage is denied.”

     However, an appeal could take months or longer, said Jenny Shapiro, and there’s no guarantee that the surgery would be approved even then. She said that by-the-book denials are making the rare disease that struck her normal 9-year-old even worse than it's already been.

www.nbcnews.com/health/obese-starving-girl-12-denied-weight-loss-surgery-rare-illness-2D11803240

It seems that 50K would have been the cost effective solution.

[Shooby]

And, you think under Obamacare that people are going to get these kinds of surgery? LOL!

[Tennesseer]

Dec 28, 2013 12:11:27 GMT -5 Shooby said:

And, you think under Obamacare that people are going to get these kinds of surgery? LOL!

  LOL!  The poster nor the article said anything about ObamaCare!  

[Shooby]

I know. Just making the point that if you think healthcare is hard to get NOW, just WAIT until the rubber hits the road.

[Deleted]

Dec 28, 2013 12:18:58 GMT -5 Shooby said:

I know. Just making the point that if you think healthcare is hard to get NOW, just WAIT until the rubber hits the road.

She'll be lucky to get her insulin paid for.

[Tennesseer]

Dec 28, 2013 12:18:58 GMT -5 Shooby said:

I know. Just making the point that if you think healthcare is hard to get NOW, just WAIT until the rubber hits the road.

Your point has zero to do with the child's story.

[Deleted]

You understand 'Obamacare' is not government owned and operated health care... Right? 

[Deleted]

Dec 28, 2013 12:22:48 GMT -5 @lonewolf said:

Dec 28, 2013 12:18:58 GMT -5 Shooby said:

I know. Just making the point that if you think healthcare is hard to get NOW, just WAIT until the rubber hits the road.

She'll be lucky to get her insulin paid for.

Yeah, just look at all the people on Medicare starving for insulin... 

Sorry OP. 

[thyme4change]

I agree that healthcare will be messy in the next 5 years.  We are going to hear more stories like this - mostly by people who are trying to sway your opinion against the new laws.  Every time the industry shifts we have to listen to a whole pack of one-off sob stories.  And we get back to the question.  Are we rich enough to save every single human from every single ailment?

[NancysSummerSip]

I'm not a fan of the gastric bypass surgery. And my doctor will sign off for absolutely no one, under any circumstances, under the age of 18. And I've seen parents bring their kids to his office, hoping, begging and pleading with him.

But this is one of those situations that is just not in the patient's control. If her body cannot tell the difference between satiation and starvation, and the core issue was a brain tumor, it's a medical issue, not a matter of choice.

I found a good story, with details, on what happened. Very tragic, and this may very well kill the child if Tricare does not reverse its decision:

www.nbcnews.com/health/obese-starving-girl-12-denied-weight-loss-surgery-rare-illness-2D11803240

[Deleted]

I do think they need to consider her situation individually. However I also see why it is a rule that needs to exist, should have been denied initially, and triggered an individual decision. I hope they decide to allow what treatment the girl needs.

[thyme4change]

Dec 28, 2013 12:36:57 GMT -5 oped said:

I do think they need to consider her situation individually. However I also see why it is a rule that needs to exist, should have been denied initially, and triggered an individual decision. I hope they decide to allow what treatment the girl needs.

I'm wondering if the initial denial is a step in the process, and now will go to individual review.  I can see how it is a money saving activity to routinely deny things that fall into a certain category, and then let the people who think they really have a case go through an appeals process.  If they individually reviewed every single case and every single request, it would drive up administrative costs quite a bit.  If they just approve everything, it will lower admin, but increase medical costs.  

Once again I would like to say that journalists are just as lazy as the rest of us.  This might be an easy story, written by the girl's family's representatives, and no further research was done to get the rest of the story.

[EVT1]

It will be appealed, but the process needs to be expedited in cases like this.

As far as Obamacare, before the ACA the insurance companies would just leave the brain tumor in the kid in the first place (well, Tricare probably would not) because it was a pre-existing condition.   Was anyone under the impression that private insurers just love paying for brain surgery?  I really miss that system

[DVM gone riding]

Dec 28, 2013 12:29:15 GMT -5 thyme4change said:

I agree that healthcare will be messy in the next 5 years.  We are going to hear more stories like this - mostly by people who are trying to sway your opinion against the new laws.  Every time the industry shifts we have to listen to a whole pack of one-off sob stories.  And we get back to the question.  Are we rich enough to save every single human from every single ailment?

Nope some people are just going to die! Next question. And yeah I got told I was cold hearted before doesn't make the cost/benefit analysis any different. I so should be an admin I can totally be cold and uncaring and just say that degree of cost simply isn't covered!

[Miss Tequila]

Dec 28, 2013 12:54:22 GMT -5 EVT1 said:

It will be appealed, but the process needs to be expedited in cases like this.

As far as Obamacare, before the ACA the insurance companies would just leave the brain tumor in the kid in the first place (well, Tricare probably would not) because it was a pre-existing condition.   Was anyone under the impression that private insurers just love paying for brain surgery?  I really miss that system

That is complete BS. My daughter was born with a bad kidney, which she had to have removed when she was 7. Her surgery was covered 100%. Can't get more of a Pre-existing condition that somehing you were born with. We changed insurance companies several times between my pregnancy and her surgery. We never had an issue.

[mmhmm]

Apparently, the case has been referred upward for review.  I expect the age limit to be dropped in this case.  The girl needs the surgery to save her life.  I understand the need for limitations, but this is a special case.  I really do expect Tricare to make it right.

That said, this is not a "preexisting condition" as that's defined, as near as I can figure.  The family was covered by Tricare when the child was diagnosed with the tumor (Dad's an Air Force veteran), so the surgery for the tumor was probably performed under Tricare coverage.  This condition is a result of the tumor and the surgery to remove it.

[Deleted]

Dec 28, 2013 19:30:56 GMT -5 Miss Tequila said:

Dec 28, 2013 12:54:22 GMT -5 EVT1 said:

It will be appealed, but the process needs to be expedited in cases like this.

As far as Obamacare, before the ACA the insurance companies would just leave the brain tumor in the kid in the first place (well, Tricare probably would not) because it was a pre-existing condition.   Was anyone under the impression that private insurers just love paying for brain surgery?  I really miss that system

That is complete BS. My daughter was born with a bad kidney, which she had to have removed when she was 7. Her surgery was covered 100%. Can't get more of a Pre-existing condition that somehing you were born with. We changed insurance companies several times between my pregnancy and her surgery. We never had an issue.

On the individual market? ... Cause the cleft my daughter was born with certainly was considered a pre existing condition...

[EVT1]

People with large solid group policies have no idea what was going on in the individual market- and weirdly that small segment is all that making the headlines today when it comes to how bad the law is.  Haven't heard a peep from anyone on a big group plan- in fact our policies went down and the company got a rebate.  But that's not news is it.

[Miss Tequila]

Dec 28, 2013 21:35:42 GMT -5 EVT1 said:

People with large solid group policies have no idea what was going on in the individual market- and weirdly that small segment is all that making the headlines today when it comes to how bad the law is.  Haven't heard a peep from anyone on a big group plan- in fact our policies went down and the company got a rebate.  But that's not news is it.

I'm on a big group plan and ours went up. I don't know many people whose insurance rates went down and quite a few self-employed individuals who had significant increases in their premiums

[Miss Tequila]

Dec 28, 2013 21:19:06 GMT -5 oped said:

Dec 28, 2013 19:30:56 GMT -5 Miss Tequila said:

That is complete BS. My daughter was born with a bad kidney, which she had to have removed when she was 7. Her surgery was covered 100%. Can't get more of a Pre-existing condition that somehing you were born with. We changed insurance companies several times between my pregnancy and her surgery. We never had an issue.

On the individual market? ... Cause the cleft my daughter was born with certainly was considered a pre existing condition...

No where in the article or in EVTs reply did anyone mention an individual policy.

[The Walk of the Penguin Mich]

The problem is that she has not stopped growing and it is difficult to get correct nutrition for an ADULT who has undergone gastric bypass. Not getting enough nutrients until at least her growth plates have closed can cause a world of problems on top of the ones that she already has.

I have a step sibling that has undergone this procedure. At this point, she has a central line providing nutrition as she can't put food through the stomach that remains and she is dropping weight far faster than she should. She's also been hospitalized half a dozen times since March due to complications.

It's not as simple as people seem to think. I imagine that they are trying to get her to the point where she is closer to her adult height before doing the surgery. That might be at 12, it might be at 16.

[Deleted]

I was asking you about your situation. I don't know about OP, but believe me, just because you never had a present at birth issue count as a pre existing condition, don't assume they don't. I know they can. 

[The Walk of the Penguin Mich]

As far as Obamacare, before the ACA the insurance companies would just leave the brain tumor in the kid in the first place (well, Tricare probably would not) because it was a pre-existing condition. Was anyone under the impression that private insurers just love paying for brain surgery? I really miss that system

As the tumor was benign, it very well may have been better to leave the tumor in place. That's not uncommon for a lot of brain tumors, particularly those around the pituitary gland. In those cases, they deal with the problem medically as long as they can. Sometimes, it never needs to be removed.

I think a lot depends upon how fast the tumor grows.

[Miss Tequila]

Dec 28, 2013 21:48:10 GMT -5 oped said:

I was asking you about your situation. I don't know about OP, but believe me, just because you never had a present at birth issue count as a pre existing condition, don't assume they don't. I know they can. 

I was replying to EVTs post. I have never had an issue with insurance and have always been happy with our coverage. Just a few months after changing jobs and insurance companies, my daughter had her kidney removed. We had absolutely no issues with the insurance company. My poin is that EVT shouldn't assume that everyone would be denied due to Pre-existing condition.

[mmhmm]

Dec 28, 2013 21:19:06 GMT -5 oped said:

Dec 28, 2013 19:30:56 GMT -5 Miss Tequila said:

That is complete BS. My daughter was born with a bad kidney, which she had to have removed when she was 7. Her surgery was covered 100%. Can't get more of a Pre-existing condition that somehing you were born with. We changed insurance companies several times between my pregnancy and her surgery. We never had an issue.

On the individual market? ... Cause the cleft my daughter was born with certainly was considered a pre existing condition...

Do you mean your insurance wouldn't cover a cleft lip repair, oped?  

[Deleted]

I was still teaching (and had a nice group policy) when it was repaired. Well, partially. She still has a small slit. When I stopped teaching and we went onto the individual market, no one would insure her for the cleft or anything related to the cleft. At that point they were not sure if she might need another surgery some day. 

She is the primary reason the kids have been on BlueChip. No pre existing condition issues. 

[mmhmm]

Dec 28, 2013 21:47:29 GMT -5 The Walk of the Penguin Mich said:

The problem is that she has not stopped growing and it is difficult to get correct nutrition for an ADULT who has undergone gastric bypass. Not getting enough nutrients until at least her growth plates have closed can cause a world of problems on top of the ones that she already has.

I have a step sibling that has undergone this procedure. At this point, she has a central line providing nutrition as she can't put food through the stomach that remains and she is dropping weight far faster than she should. She's also been hospitalized half a dozen times since March due to complications.

It's not as simple as people seem to think. I imagine that they are trying to get her to the point where she is closer to her adult height before doing the surgery. That might be at 12, it might be at 16.

Gastric bypass surgery is certainly nothing to be taken lightly.  It's something that either goes very well, or very, very badly.  In this child's case, it may be they don't feel they have the time to wait, as she's gaining too quickly and beginning to suffer serious complications.  There's just no way to tell from the articles we're reading, I'm afraid.  I've not personally seen a case like this, so I have no clue.

[mmhmm]

Dec 28, 2013 22:03:42 GMT -5 oped said:

I was still teaching (and had a nice group policy) when it was repaired. Well, partially. She still has a small slit. When I stopped teaching and we went onto the individual market, no one would insure her for the cleft or anything related to the cleft. At that point they were not sure if she might need another surgery some day. 

She is the primary reason the kids have been on BlueChip. No pre existing condition issues. 

Ahh.  That makes more sense.  Thanks for the explanation, oped.

[Miss Tequila]

Dec 28, 2013 22:03:42 GMT -5 oped said:

I was still teaching (and had a nice group policy) when it was repaired. Well, partially. She still has a small slit. When I stopped teaching and we went onto the individual market, no one would insure her for the cleft or anything related to the cleft. At that point they were not sure if she might need another surgery some day. 

She is the primary reason the kids have been on BlueChip. No pre existing condition issues. 

Gotcha. I made it a point to never go without a group policy. 3 out of 4 of us have Pre-existing conditions.

[DVM gone riding]

and as the case seen with that poor girl in CA surgery isn't simple and shouldn't be taken lightly, putting this child through another surgery that she needs primarily as a result of her first surgery could add even MORE complications. The medical insurance as the policy in place for very legitimate reasons. I am sure being tricare and one of the best insurances out there that they will review the case carefully and make a legitimate decision. at some point the girl will most likely get the surgery its just a case of when. I wonder if they are making it worse with such restriction of diet 900 cal isn't very much and her body thinks it is starving so it is trying to store them all.