Liv_94

On 11/7/2023 at 8:25 PM, Ambular said:

Surgery date is scheudled for the end of this month

Congratulations!!! Glad they decided in your favor. It’ll all be worth it!

On 10/24/2023 at 2:38 AM, Ambular said:

wow yeah that is much shorter...I also had to ask my baratric team for a copy - as I still havent recieved one from BCBSNC. Well I sent over my "compliance" with diet and exercise from the first surgery...hopefully its enough info. I also sent in proof I was proscribed anti acids for months during my pregnancy and doctors notes on how intolerable it was to eat and take meds with my gerd...

we will see if thats enough with the peer to peer review...I'll keep updating on here when I hear something.

you give me hope...thank you for sharing!

I really hope they review quickly and reverse that decision for you!

2 hours ago, Ambular said:

BTW this is what BSBCNC said to me. They just seem like they auto deny and don't even check records as we have been so compliant and have plenty of evidence. It sucks because I don't even live in NC - I only have this because I work remoltely for a company in NC and live in CA..

We are gearing up for the peer 2 peer now but here is what was said:

Revision of a primary bariatric surgery to a gastric bypass is covered when you meet one of the following scenarios:

(1) You have regained weight after your original surgery. In this case, you must continue to meet basic criteria for weight loss surgery, including nutritional and psychological assessments, and you must have documentation of compliance visits (including compliance with nutrition and exercise recommendations) after your previous weight loss surgery

(2) You have severe reflux disease that has not been responsive to optimal medical management (maximum medication therapy, diet alteration with the assistance with a nutritionist, and change in activity and positioning). Failure of medical management must be documented, and studies to support persistent untreatable reflux must be submitted.

Review of your provided records reveals that you have regained weight after your previous surgery; however, we have not been provided with compliance records from your prior post-surgical visits. Additionally, it does not appear you have undergone optimal medical management for your reflux or that studies show severe signs of reflux.

Wow that’s more detailed than what they said to me. I don’t live in NC either my company is based in NC as well and this was the letter they sent me

7 hours ago, Ambular said:

That is really good to know. My particular situation is I had a baby eariler this year and gained 80lbs from pregnany. I"m 6months post partum and still breastfeeding so that makes me super nervous but docs say I should get the revision.

For me I think I should’ve gotten a bypass in the first place but my pcp said I was so young and the sleeve was good so I just went along with it. At first I had no intention to get a revision even though I had gained almost all the weight back but I’m glad I did and I have no regrets.

1 hour ago, Ambular said:

Thank you for the insight! I definitely need to slow my eating down too - what is foamies? I dont think I’ve experienced that with sleeve.

I did not experience it with the sleeve either only when I had the bypass. It’s like being on the verge of throwing up, it’s kinda like when a baby spits up. Not pleasant at all and the only thing that really helps that for me is actually throwing up.

8 minutes ago, Ambular said:

Wow that’s amazing progress! I’m so thankful you responded back to me! Sounds like you’re having a happy ending. Any advice on the revision? Anything you would change or prepare for? What would you tell yourself before the surgery?

I would definitely say for the first few weeks don’t be discouraged! When I got home from the hospital I was 10 lbs heavier and it took some time to get that off and actually start losing. Also for myself I thought I could still eat at the speed I used to which was a big mistake that I’m still working on even now! I need to chew throughly or my stomach will definitely hurt. I’ve gotten better though because my first few months I would either throw things up or get the foamies. Lastly I can still tolerate things like sugar in small amounts but you’ll quickly learn that it really just depends on what it is. I’ve eaten a donut with no problem but then a few weeks ago I had a small bowl of Cinnamon Toast Crunch and was in the bathroom 3 times in an hour. I do mostly sugar free things but occasionally I’ll have something with regular sugar so it’s good that I know what I can and can’t tolerate.

8 minutes ago, Ambular said:

Congrats!! I'm so happy for you! how has your journey been with revision?

Thank you! So far really well, on my surgery day in Dec 2022 I started at 265 and I’m currently down to 195

15 minutes ago, Ambular said:

hello there! Any updates? I"m in the same situation with BCBSNC...wondering what happened. I'm in the middle of proving to them that I followed instructions...

My doctor ended up doing a peer to peer with the insurance company and then it was approved and I had it as planned!

8 hours ago, KimA-GA said:

are you doing any weight management appointments with a dr or nutritionalist? if that’s their denial reason, then it won’t hurt for you to do it while it gets sorted out..

may be able to manage GERD better in the meantime if a nutritionist who understands consults with you..

drs offices deal with denials all the time and are good at sorting it out, especially if you do everything you can to speed it up on your end

I did several appointments with the nutritionist before they submitted and that was another thing they tried to say I didn’t do so I’m not really sure what’s going on.

27 minutes ago, SleeveDiva2022 said:

I'm surprised the surgery was scheduled before having insurance approval. Is it possible to maybe find another doctor (I have BCBS of Illinois and they wouldn't allow the surgery to happen if the doctor AND the hospital weren't both in network) and see if they can get the surgery approved based on your new comorbidities.

I know the insurance company is lying by saying the doctor is not in network because he already performed an endoscopy on me with no insurance issues. The doctors office accommodated me by giving me a surgery date because my employer was harassing me to give them information about when I’d be out and how long.

Well according to doctors office the insurance was trying to say he was out of network as an excuse. The hospital is in network and he’s employed by the hospital so he would be in network is what they told me. The doctors office has submitted information to my insurance company showing previous encounters notes with my past doctors so we’re waiting to hear back from that. They told me they will do a peer to peer if necessary. This just all stinks because my surgery is already scheduled and I am already on the liquid diet.

Hello everyone, I’ve gone through the long process of trying to get a revision surgery after gaining most of the weight back after having the sleeve in 2014. I’ve had mental health issues in the years following and also developed GERD and High blood pressure in the recent years since. The insurance company (BCBS of North Carolina) has been giving me issues from the start first saying that my surgeon wasn’t in network so they wouldn’t cover the surgery. Upon further investigation from my doctors office the real issue was them denying my claim for a revision because there was a lack of evidence showing that I followed proper diet and exercise after my first surgery. Has any experienced something similar? I have the two comorbidities and my bmi is currently 45 so I’m just kinda in shock they denied me especially without even informing me.