My Band to VSG Revision BCBS Appeal Letter/Life with the Band

[kshallow 9]

This is the letter which was submitted to BC (in addition to my med records and other supporting documentation) I did win the appeal and my band to VSG surgery is scheduled for April 5th. This is also my account of life with the band for those who are seeking experiences from all sides

Hello,

I had the lapband procedure three years ago (2010). Initially, everything seemed fine but only a few months after having this procedure, problems began including the inability to swallow solid food, acid reflux, night cough, vomiting, and constant pain and pressure in my upper back and chest. For the next two and a half years, my life was a series of doctors appointments having the band filled and unfilled as well as upper GI's (the current count is 6) to view the band placement and swallowing ability, and try to determine the source of all the problems. Despite these chronic issues, I followed all the nutritional recommendations of the band "lifestyle" and was successful in losing over 80 pounds during this timeframe.

In the past year, the physical problems persisted to the point that even when I was able to eat healthy solid food, I was living in a constant state of pain and discomfort and frequently vomiting. I recently had another upper GI test done at St. Joe Hospital Tuesday 1/15/13 with a follow up appointment the next day with my surgeon. The band has indeed slipped down my stomach and the films clearly show a portion of my stomach protruding over the band way out of placement.

After meeting with my surgeon following this last upper GI, it is his recommendation the band be removed. He, as well as the surgeon's insurance coordinator advised me that insurance will cover the removal and/or placement of a new lapband. It is the opinion of both myself and my surgeon that placing another lapband and/or repositioning the current lapband is not a smart decision given the history of chronic pain and problems associated with my body and the lapband. It is my surgeon's recommendation that upon removal of the lapband, he perform a vertical sleeve gastrectomy (VSG) procedure at the same time. This is a covered bariatric procedure which involves no foreign article in the body as does the lapband. It is my desire to have the lapband removed and have the VSG procedure done.

I have been informed that to qualify for the VSG procedure, I would need to meet the initial qualifications for bariatric surgery (a BMI of at least 35 with co-morbities). If this were the case, the last three years of my life working hard to lose 80 pounds in spite of living in chronic discomfort and often inability to eat for days or weeks on end would be in vain. I do not want the ineffectiveness of the lapband to be a factor in my desire to remain healthy, maintain a low BMI, and to be able to eat solid healthy foods. To suggest I need to GAIN weight in order to qualify for a bariatric procedure that works for me goes against the entire idea of getting the surgery in the first place.

I am writing requesting the removal of my current lapband and VSG procedure being done at the same time be covered by insurance. Currently, I am only able to drink liquids, eat very few soft foods, and know that even with these things, swallowing often brings pain and vomiting. I am tired of living in pain due to the mechanical failure of the lapband. There have been nights when I have not even been able to swallow my own saliva. Currently, there is no Fluid in the band at all. It is wide open and still feels like a vice around my chest when I swallow food. I started this journey with the goal to get healthy and be at a healthy BMI. That remains my goal today.

I followed the protocols for qualifying for initial bariatric surgery in 2010. I met the requirements, I attended the seminar, I did all the reading. I learned all the nutritional guidelines and stuck to them as the band allowed (resulting in a large weight loss) I followed my doctor's directions, dutifully had the band filled and unfilled as directed. I went on liquids when directed, ate when directed, and refrained from eating when directed. I went through 6 UGI's complete with barium swallows as directed. I did everything I was supposed to do in order to make my life with the lapband successful. As my doctors will attest, the mechanical failure of this lapband is not due to any lack of efforts on my part. I had been unable to sustain weight loss before bariatric surgery and now with a slipped band and the need for its removal, I am facing the same situation as I was in 2010. I have worked very hard for the weight loss I have achieved and it is very likely I will be unable to maintain my weight loss without further surgical intervention.

Blue Cross was supportive in my initial request for approval for lapband surgery and I am hoping Blue Cross will be supportive in covering the lapband to Vertical Sleeve Gastrectomy revision surgery. I have done everything on my part at my doctor’s direction and now I am appealing to you to help me move on with my life with VSG. I will also appeal from a monetary standpoint. Following this letter, please find an itemized list of the BCBS money that has already been spent due to my lapband complications. I am displaying this because VSG is a one time surgery with very little follow up necessary. There is no need for ongoing check ups, UGI’s, or lapband adjustments. This revision surgery makes sense from a physical quality of life standpoint as well as monetary one.

My surgeon is recommending this revision surgery and will be forwarding my medical records, UGI results, and his recommendations to you as well. Dr. Jacob Roberts, DO is my surgeon and has graciously offered to meet with a medical review team or director in order to directly discuss the need for this revision surgery (please find his contact info attached) Also, please feel free to contact my surgeon’s office as well as the insurance coordinator for any additional records or information you may need.

Thank you for taking the time to review my case.

This is the letter which was submitted to BC (in addition to my med records and other supporting documentation) I did win the appeal and my band to VSG surgery is scheduled for April 5th. This is also my account of life with the band for those who are seeking experiences from all sides

[ISleevedIt 379]

Good for you! Very informative letter without any hostility. As you can see, I would not be good and writing such a letter.

[kshallow 9]

ISleevedlt: Trust me! The far nastier version was being written mentally!! (with mannnnyyyy choice words) about my first surgeon and his "BANDAID" approach to band problems. So glad to be actually looking forward to this surgery and moving on while leaving that damn lapband in the dust!!!

[catheryn3 7]

The band was my 1st choice for weight lost surgery,but the more I read up on the lap-band the more I realize the band was not for more I decided that if I was going to have surgery I needed something that would work for me the rest of my life, not for the short term, so I went for the gastric sleeve surgery, I had it done on 2-14-13 got up 3 hour's after the surgery after the nurse woke me up and start walking, no pain just a little sore like I had done 50 sit up's went home on the 2-15-13, throw-up a few time's but nothing I couldn't handle didn't need the pain med' for pain from surgery, but needed pain med for my other problem's, I have lost about 37lb; don't regret the sleeve at all would like everyone who want to get weight loss surgery because they need it to go for it, God Bless everyone.

[Ms.AntiBand 2,984]

You are so smart NOT to be banded again. Your docs were correct.. And glad you listened to them.

OMG.. You reminded me of the night coughs.. Those were awful! I used to cough up black blood! Some times I was so tired I would wake up to blood all over myself because I didn't wake up.

Ok anyway .. So happy you get to be sleeved.