Is surgical reversal "medically" necessary?

[bee in my bonnet 0]

Hi All,

I wasn't sure if I should post this in the insurance forum or this one. I will start here.

I was banded in 2008. I have had problems from the beginning but nothing concrete has ever shown up on any testing. I throw up daily, occaisional chest pain and bad port site pain, espeically when I am stressed out. From 2008-2011, I only lost 25lbs, kind of an epic failure. In 2011, I started Medifast and then lost 80lbs. I had to stop it last year due to monthly cost of $350.00 and have since gained back 90lbs. My BMI is now again at 40.3. Not good. As none of my tests have ever come back with anything conclusive (no obstruction, no stricture), I am not sure if Cigna will deem my revision as "medically necessary". My doctor appointment is on friday and I want to go in prepared and to not say the wrong thing. If any of you has had a revision and NOT had serious complications, can you let me know?

I am pasting my policy coverage below, what do you think of the wording?

Reoperation and Repeat Bariatric Surgery

:

Cigna covers surgical reversal (i.e., takedown) of bariatric surgery as medically necessary when the

individual develops complications from the original surgery such

as stricture or obstruction.

Cigna covers revision of a previous bariatric surgical procedure or conversion to another medically

necessary procedure due to inadequate weight loss as medically necessary when ALL of the following

are met:

•

Coverage for bar

iatric surgery is available under the individual’s current health benefit plan.

•

There is evidence of full compliance with the previously prescribed postoperative dietary and exercise

program.

•

Due to a technical failure of the original bariatric surgical pr

ocedure (e.g., pouch dilatation) documented

on either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD), the individual has

failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body

weight

or failure to achieve body weight to within 30% of ideal body weight at least two years following

the original surgery.

•

The requested procedure is a regularly covered bariatric surgery (see above for specific procedures).

NOTE:

Inadequate weight loss due

to individual noncompliance with postoperative nutrition and

exercise recommendations is not a medically necessary indication for revision or

conversion surgery and is not covered by Cigna.

Cigna does not cover

surgical reversal (i.e., takedown) or revis

ion of a previous bariatric surgical

procedure or conversion to another bariatric surgical procedure for ANY other indication b

ecause it is

considered not medically necessary.

Thank you to all that can share.

Best,

~Bee

[thesuse2000 698]

I was a revision from band to sleeve. Frankly, I'm not 100% clear on how the office presented my case to my insurance company (I thought it best to stay out of it), but they are pros and know what they're doing. If you go to a big bariatric practice they will be able to advise you. They'll probably send you for tests, like an esophogram and/or an endoscopy to look for evidence of damage/complications. I know for me it was "good" that my BMI was over 40 when I started the insurance process - at least with my insurance, they said that even if they don't cover it as a revision it should be covered as a new surgery with a BMI over 40. But it was covered as a revision. Good luck!

[thesuse2000 698]

I just read through the info in your post in more detail... the thing I had going for me is that I did lose 70 pounds originally with the band and regained after a slip, and continued night choking even after revision surgery... so I may have passed the rules about having complied with my first surgery, where that might be more of a fight for you... but talk to the office and see if they have suggestions for you - they just might! Perhaps your great commitment to the medifast diet will help. I hope so.

Edited June 26, 2014 by thesuse2000

[msfitn2014 248]

my insurance covers revision as medically necessary. it was I had to have a bmi of 40 or more or if I was less than 40bmi I had to have 2 comorbidities.....When I first went I didn't have a bmi of 40 so I had to gain weight to get to 40. I didn't have any high blood pressure, diabetes, high cholesterol, sleep apnea or anything like that. I didn't take meds for anything!! Complications from the band, I had reflux, dilated pouch and something was wrong with my esophagus.

[Dreamer88 2]

I am havin revision surgery in Sept. Ha lots and lots of complications with the band, yet nothing saying I had dysphagia (problems swallowing) was documented in my char. I had port site pain since I had the lap band done and that was documented, but my insurance company wouldn't deem revision "medically necessary". They could take the ban out with no problems, but may have not covered revision. So I have had t go through all the same stuff as I had to before I got my band ( 6 months documented dieting, pych eval, etc, etc). They will do it as a new surgery but you have to jump through hoops again. That is how it is with my insurance anyways. I have Blue Cross Blue Shield of Michigan.

[chris73 38]

the individual has

failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body

weight

That section in itself would say that you could revise to another procedure

[LSF 264]

Bee-

I have Cigna also with the same info. What ended up happening with your surgery? Your story sounds just like mine