Band to Sleeve Revision Insurance Approval

[Thom1955 0]

Sadly, after two years, my lapband slipped. I've had success with the band and lost over one pounds. I was suffering horrible acid reflux, had a EDG (scope thingy) done and learned that I had Barrett's Esphogus and that my band had slipped. My doctor (Dr Oh, Federal Way, WA - he is excellent) told me that I needed to have a revision, that it was my fault for the slippage as I wasn't chewing enough and eating too much (ok?) and that if I didn't have the sleeve, I would get FAT again! I am so content at my current weight - I'm right where I'm suppose to be. So anyway, long story short, he unfilled me, and I'm already back to old eating habits. In one week, I've put on 5 lbs. Yikes, at this rate!!!! in six months, I'll be back where I was.

Anyway, he told me insurance would not cover a revision. I'm reading through some of the blogs and it seems insurance has covered some revisions - does anyone know if Blue Cross Premera, WA state, cover lapband to sleeve revisions - does anyone know the procedure code? I am still reading up on the sleeve, but, think I want to do it - can't afford to pay it out of my own pocket but, can't afford to let myself get unhealthy again either!

Thoughts, ideas, suggestions - would love to hear from any - seems all revisions I've read about by members of this group are happy with their choices!!

Thanks all!

TKT2FLY aka Tom

[Tiffykins 672]

My revision was covered by insurance. But, my husband is in the military, and I had to meet certain requirements again, I had to have the procedure at a military hospital that performed the VSG, I couldn't travel more than 100 miles from our home base to have it done, and if we happen to get orders, and I go to a base that does not do the sleeve, or I have complications related to the sleeve and I have to go to a civilian ER my insurance will not cover any of the costs of the complications. So, while some may consider Tricare a cadillac insurance policy, we have to jump through some hoops and take some risks to have the surgery of our choice.

I am beyond happy with my choice of VSG for my revision. I had the option of RNY or a band revision. No way in hell was I going to have another band put in, and RNY just was not an option for me. I'm sorry that your band surgeon made those comments about your slippage being your fault. I had the same issues with my band surgeon. He actually blamed my port flipping on me having wild sex. Sadly, my husband was off in NJ for pre-deployment training, so I wasn't getting laid.

The stats with the band have declined especially in the last year. Even the manufacturers of the bands have had to change their stance, and safety warnings as stats are pouring in for revisions. 1 in 4 band patients will have to have a revision of some sort due to slippage, erosion, port flipping, esophagus dilation, severe acid reflux within the first 5 years of having their bands placed.

Calling your insurance company maybe the very best option to find out about revisions. A lot of insurance companies are going to a "one WLS per lifetime". I'm not familiar with your insurance, but I hope you get some answers soon.

[ShellieB73 0]

I can't believe that some companies will say one WLS per lifetime....that seems so discriminatory. We are people trying to get healthier!!!!

Is this going to become the standard? I have a hard time believing that because of a mechanical failure (slippage) in a tool that worked at the time, it would completely disqualify a patient from another procedure.

What is health care coming to?

[pnw218 14]

Hi Tom! I am just a little south of you!

It doesn't seem like your current dr is going to be very helpful or proactive. Maybe you could gather some stats on how many bands slip and what the usual cause is? If you know that it wasn't your fault, then I would definitely pursue it. There seems to be a ton of Lapband ads on tv right now for surgeons in the area. Totally drives me nuts now that I know more about bands.

I would think your doctor wouldn't pass up the chance to make a little more money - does he do the sleeve? Maybe you can convince him to help with letters to your insurance. If not, maybe a free consulatation with an attorney.

Good Luck!

[TexasT 99]

I have Blue Cross/Shield of Alabama and they don't cover anything WLS related. I was self-pay with the band, and again with my revision. Though I also had my gall bladder out, so insurance paid for that part and also for the hospital stay, etc.

[brittu 42]

Medicare and many insurance companies cover appeal with out any requirement but failure of the first procedure. And the policy of the ASMBS (American Society for Metabolic and Bariatric Surgeons) says the same thing.

If it helps, I posted my lastest appeal letter containing my research on revision coverage at:

My Revision Appeal: From Lap Band to VSG

Britt

[Thom1955 0]

Thanks everyone for your responses - Brittu - love the appeal letter and saving it just in case - I had another EDG done 2 days ago and my dr. gave me three options - remove band, have band repaired, but know, possibly same thing will happen or go with the sleeve.

He again told me insurance probably won't cover it - I got the CPT # (43775) and my insurance Premera BC/BS says they will cover if medical necessity - my dr will write it is medical necessity so I'm hoping - they are submitting the paperwork to insurance company - fingers crossed here - I really liked the band the first year - again, I lost over 120 lbs - now with the slipped band and it being unfilled, I've put on 25 lbs in six weeks - I don't want to get heavy again - so, thanks for all the encouragement - I'm still learning about the sleeve and read everything I can - I'm optimistic from reading what I've read so far - fingers crossed - ! Tom

[achopp 0]

Thanks everyone for your responses - Brittu - love the appeal letter and saving it just in case - I had another EDG done 2 days ago and my dr. gave me three options - remove band, have band repaired, but know, possibly same thing will happen or go with the sleeve.

He again told me insurance probably won't cover it - I got the CPT # (43775) and my insurance Premera BC/BS says they will cover if medical necessity - my dr will write it is medical necessity so I'm hoping - they are submitting the paperwork to insurance company - fingers crossed here - I really liked the band the first year - again, I lost over 120 lbs - now with the slipped band and it being unfilled, I've put on 25 lbs in six weeks - I don't want to get heavy again - so, thanks for all the encouragement - I'm still learning about the sleeve and read everything I can - I'm optimistic from reading what I've read so far - fingers crossed - ! Tom

I have Premera BC. I was denied the VSG surgery because Premera considers it "investigational". I appealed their decision 3 times, including one appeal that was done by my surgeon. I also appealed to an Independent Review Organization (IRO). Unfortunately, all my appeals were in vain and Premera's "investigational" VSG policy held up. I ended up having to pay for the surgery myself. I was not a band to sleeve revision patient though, so maybe there is a difference.

I was also told by Premera that as long as I met the BMI qualifications (which I did) and had a letter of medical necessity (which I also did) the surgery would be covered. When my surgeons office submitted the paperwork though it came back denied with the reason being the investigational bs. They totally got my hopes up and then broke my heart.

Anyway, I hope you get approved but I just wanted to let you know that Premera is pretty firm with their policy regarding VSG. :thumbdown:

Edited June 3, 2010 by achopp

[Thom1955 0]

Finally after nearly 4 weeks, I have heard from BC/BS Premera - DENIED!!!! I'm so upset. I've thought about the appeal process and really appreciate the appeal letter that Brittu has shared - I may be using it - if not the sleeve, perhaps band repair will be covered - I've put on over 40 lbs and really getting into a rut and eating like a madman - absolute food addiction I have - totally bummed -does anyone know if band repair is usually covered by insurance - feel like I have no options - to top it off, my band is of course still in place, unfilled, and I've been PBing adn Sliming for 2 days nonstop with a pain so bad - think I have a lodge cashew - anyone have words of encouragement - I see doc next week - by the way, he is really good, no bedside manner, but, good at what he does - Dr Oh, Fedl Way, WA

[mila1013 0]

Finally after nearly 4 weeks, I have heard from BC/BS Premera - DENIED!!!! I'm so upset. I've thought about the appeal process and really appreciate the appeal letter that Brittu has shared - I may be using it - if not the sleeve, perhaps band repair will be covered - I've put on over 40 lbs and really getting into a rut and eating like a madman - absolute food addiction I have - totally bummed -does anyone know if band repair is usually covered by insurance - feel like I have no options - to top it off, my band is of course still in place, unfilled, and I've been PBing adn Sliming for 2 days nonstop with a pain so bad - think I have a lodge cashew - anyone have words of encouragement - I see doc next week - by the way, he is really good, no bedside manner, but, good at what he does - Dr Oh, Fedl Way, WA

I am going to assume you were denied for the sleeve? Denial for the sleeve has nothing to do with band complications. Band complications like erosion, slippage are medically necessary and do not require pre authorization as they can be life threatening

[FitatFifty 11]

Tom

I too am with Premera BC and was initially told they would cover the VSG. However, like others who posted replies, Premera denied my request while approving me for gastric bypass. I am in the process of my level one appeal and have found numerous studies supporting VSG. Go to pubmed.gov and search for lap band revisions or sleeve gastrectomy. You will find numerous studies released since Premera revised its medical policy in November 2009. You didn't state the reason for the denial, but focus on that reason and show them with studies why teh denial should be overturned.

Also, I noticed that Premera has revised it policy several times in November, so we may receive an update soon. If Medicare makes the leap, then other insurers are soon to follow.

Hang in there! We can work together to solve this issue. Feel free to contact me by email.

Catherine (aka FitatFifty (ok I'm trying!))

[susan42 0]

[font=Comic Sans

"I am beyond happy with my choice of VSG for my revision. I had the option of RNY or a band revision. No way in hell was I going to have another band put in, and RNY just was not an option for me. I'm sorry that your band surgeon made those comments about your slippage being your fault.

The stats with the band have declined especially in the last year. Even the manufacturers of the bands have had to change their stance, and safety warnings as stats are pouring in for revisions. 1 in 4 band patients will have to have a revision of some sort due to slippage, erosion, port flipping, esophagus dilation, severe acid reflux within the first 5 years of having their bands placed."

I just wanted to let you know that it sounds like you're on the right track. I have been banded twice and as a result of the second band I have gained all of my weight back:cursing: I think opting for the sleeve sounds like a good choice. Hopefully your insurance company will reconsider. Good luck!