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Frustrated about insurance!



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I spoke with the insurance coordinator for my new surgeon's office today. She says that even though he says that a revision to the sleeve is medically necessary, my insurance will probably not pay for it. Apparently, my insurance makes patients meet all the same restrictions that they had to meet for the first surgery, including having a high BMI for two years before the revision, regardless of whether the revision is because of complications from the original surgery (severe pouch dilation in my case). I'm ready to scream. My insurance is excellent except for this one clause.

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I spoke with the insurance coordinator for my new surgeon's office today. She says that even though he says that a revision to the sleeve is medically necessary, my insurance will probably not pay for it. Apparently, my insurance makes patients meet all the same restrictions that they had to meet for the first surgery, including having a high BMI for two years before the revision, regardless of whether the revision is because of complications from the original surgery (severe pouch dilation in my case). I'm ready to scream. My insurance is excellent except for this one clause.

What insurance do you have? Mine had the same clause...Aetna. It's a ridiculous requirement for revisions!! I was denied initally for the same reason. My doctor did a peer to peer...denied again but then I wrote an appeal letter and won....quickly too. I can send you a copy of it if you'd like.

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What insurance do you have? Mine had the same clause...Aetna. It's a ridiculous requirement for revisions!! I was denied initally for the same reason. My doctor did a peer to peer...denied again but then I wrote an appeal letter and won....quickly too. I can send you a copy of it if you'd like.

I have Federal Blue Cross Blue Shield, and my policy doesn't state any exceptions for revisions due to band failure. The likelihood that my insurance company will change their minds about a denial is extremely slim. There's a member here or at OH that had the same company and was in a similar situation as me (located in the same state and even had the same surgeon), and she couldn't get them to change their denial at all and eventually gave up and had to go to Mexico to get her band. I think that what I've decided to do is to focus my energy right now on getting approval for getting my band repositioned and then saving up to possibly self pay in the future. I would like to give my band one more chance, since it worked very well for me until I became too tight and caused a lot of problems for myself. I work for the federal government, so if I have to, I do have the option of changing insurance companies in the future if my band fails again. The other insurance company would be SAMBA/Cigna, and it has a seemingly more lenient policy on revisions due to complications, but I've heard stories of what a nightmare they can be to get approved, too.

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I have Fed BCBS too...I gave up fighting and went to Mexico. Best wishes to you and your success!!!

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What insurance do you have? Mine had the same clause...Aetna. It's a ridiculous requirement for revisions!! I was denied initally for the same reason. My doctor did a peer to peer...denied again but then I wrote an appeal letter and won....quickly too. I can send you a copy of it if you'd like.

would you send that to mr please.

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    • Doughgurl

      Hey everyone. I'm new here so I thought I should introduce myself. I am 53y/o and am scheduled for Gastric Bypass on June 25th, 2025. I'm located in San Antonio, Texas. I will be having my surgery in Tiajuana Mexico. I've wanted this for years, but I always had insurance where bariatric procedures were excluded. Finally I am able to afford to pay out of pocket.  I can't wait to get started, and I hope I'm prepared for the initial period of "hell". I know what I have signed up for, but I'm sure the good to come will out way the temporary period of discomfort and feelings of regret. I'd love to find people to talk to who have been through the same procedure or experience before. So I look forward to meeting you all. Hope you have a great week!
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    • Alisa_S

      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 0 replies
      1. This update has no replies.
    • Alisa_S

      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 1 reply
      1. summerseeker

        Life as a big person had limited my life to what I knew I could manage to do each day. That was eat. I hadn't anything else to look forward to. So my eating choices were the best I could dream up. I planned the cooking in managable lots in my head and filled my day with and around it.

        Now I have a whole new big, bigger, biggest, best days ever. I am out there with those skinny people doing stuff i could never have dreamt of. Food is now an after thought. It doesn't consume my day. I still enjoy the good home cooked food but I eat smaller portions. I leave food on my plate when I am full. I can no longer hear my mother's voice saying eat it all up, ther are starving children in Africa who would want that!

        I still cook for family feasts, I love cooking. I still do holidays but I have changed from the All inclusive drinking and eating everything everyday kind to Self catering accommodation. This gives me the choice of cooking or eating out as I choose. I rarely drink anymore as I usually travel alone now and I feel I need to keep aware of my surroundings.

        I don't know at what point my life expanded, was it when I lost 100 pounds? Was it when I left my walking stick at home ? Was it when I said yes to an outing instead of finding an excuse to stay home ? i look back at my last five years and wonder how loosing weight has made such a difference. Be ready to amaze yourself.

        BTW, the liquid diet sucks, one more day and you are over the worst. You can do it.

    • CaseyP1011

      Officially here for a long time, not just a good time💪
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    • KimBaxleyWilson

      Three months and four days ago... I was in Costa Rica having a life changing surgery! Yesterday we had a followup visit with Dr. Esmeral via video chat and this morning my middle number changed.  I'm down 47lbs and two pants sizes. I can wear a Large tshirt for the first time in like... 14 years! Woot!! Everything is going great. I have zero regrets. I went down to the riverwalk with a friend and walked 2 miles on Monday without even getting fatigued. And no more snoring or chugging pickle juice for crazy leg cramps! I need to go to the gym more... I'm making new shirts next week so that will motivate me. LOL But I'm also just not as TIRED all the time! I have a LONG way to go...but seeing the progress on the scales and in the mirror is a huge motivator!! Thank you all for cheering me on and supporting me!!
      · 0 replies
      1. This update has no replies.
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