Does it have to be Dr Shen? They do have pouch doctors at IBD clinic at NYU, I see a Dr Shannon Chang, she specializes in J-Pouch. May be they will accept your insurance.

Jacob,

I have fought this same issue previously over another Pouch expert, and I find it odd that they have put the burden on you and your GI to determine that  "there is no one in network and in my city qualified to deal with my chronic issues related to my J-Pouch", when they should have the burden of stating who in network has such experience. When I ran into this issue in 2009, and my Connecticut insurance company pulled the plug on a New York City pouch expert (a Shen type in his day but I believe he is now retired), they sent me a letter setting forth the name of allegedly equivalent specialists in network in CT. Sure enough, one of them- and he eventually became my GI- was mentored by Bo Shen at the Cleveland Clinic and was then working at Yale- Dr Oikonnomou. And he became my GI for 6 years and took very good care of me (he actually spoke to Shen every week and discussed my case with him).

So my point is I don't understand why it's your burden to show that nobody in network has such expertise when it should be their burden to show you who does. It sounds to me like an unfair insurance practice, or what can at least be argued to be one. How would you or your GI know and isn't it the insurance company's responsibility to know what the expertise is of their own in network providers? I think the burden of providing this information should be on them and not you and your GI. I would go back at them and ask them to tell you who in network has the equivalent expertise to Dr. Bo Shen and if they can't provide names, file a complaint with the insurance commissioner. That position they are taking seems like nonsense to me and I wouldn't stand for it!!!

FYI it looks like Peter Rubin is still practicing. He might be in his 70s now but if you are in NYC he has tons of experience with problem pouches and treated mine for 18 years:

https://www.mountsinai.org/profiles/peter-h-rubin

I think the answer above is the best. I would try the answer above. If that does not work, then definitely do not lose hope. If you ever need Dr. Shen's email, let me know. I am not sure if he can help on this matter or not but let me know.

Keep us updated, good luck

The degree to which a particular health insurance policy is restrictive about who you can see varies a lot - it has nothing to do with the health insurance marketplace. I get my insurance through the marketplace, but I chose a Blue Cross plan with a broad, national network (that’s more expensive, unfortunately). Hopefully at the next open enrollment period you might have more flexible insurance options available. I know this doesn’t help much now, but it’s worth tucking away for later. In the meantime, have you looked hard at the other medical options available within driving distance? Heck, maybe you could at least find someone who would help you make your case for prior approval for a Bo Shen consultation. How much would an out-of-network consultation with Bo Shen cost? You probably have some out of network coverage, though the deductible may be high.