Insurance denied revision to bypass from sleeve

[lulugirl 20]

Sleeved July 2012 in Mexico with Dr Garcia. My BMI was about 37 y insurance wouldn't cover surgery due to not having any co-morbidities. I also had a lap band done July 2007 in Mexico with Dr Aceves & had that removed July 2010 which insurance did pay for.

I have had constant issues with reflux with my sleeve. I have lost weight & have been keeping it off but very difficult for food to stay down. I am also lactose intolerant since my sleeve surgery!

I had GI tests done to confirm my GERD issue, the surgeon feels the only way to fix it is to have a "gastric jejunostomy". This is basically a revision to a gastric bypass. I was scheduled for 718/14. Today I get a phone call from the coordinator who said it was denied by my insurance. I am copying the reason from his email below:

MMSI denied based on benefit interpretation. Procedure is non-covered and is an exclusion on Bariatric Surgery policy under heading “Not Covered/Exclusions”:

• Complications of (any) bariatric procedure when surgery was performed without meeting criteria for the procedure.
• I.E. gastric band and sleeve gastrectomy done at an outside institution (didn’t meet criteria)

I am so upset, basically he told me I could appeal. Well I called the insurance company, spoke with a rep who advised I cant appeal due to it being a "pre-determination issue" If I go ahead & have the surgery & am denied, I could then appeal"

Well I don't want a 50K bill from the hospital, so I cancelled the surgery.

It is weird but when I came back from Mexico form being sleeved, I had C Diff & was hospitalized twice, insurance paid for all of it! Again they even paid for my lap band removal which was removed due to difficulty eating fruits, veggies, meat in 2010...

I continually throw up throughout the day after I eat, alot of liquid & small pieces of food..

Also my husband is covered under my insurance & he is on dialysis 3 days a week & on a kidney transplant list,, Maybe my insurance feels we are costing them too much..

I just don't know what to do anymore..

[JillC878 59]

I am so sorry for all you are going through (and have gone trough). Unfortunately I have no advice for you, but I can offer a listening ear and a shoulder to cry on. If you ever want to talk, I am here.

[swimbikerun 1,038]

Yeah same thing as Jill above. I don't know what to say ... except wow!

[lulugirl 20]

Thanks everyone for your replys.. I am so scared now that if I get a leak or something goes wrong with my sleeve, my insurance will never cover it..

I am covered by my insurance through my employer, been working there for 9 years. It is a large organization in Arizona. Stil kind of shocked it was denied.

[VSGAnn2014 12,992]

Thanks everyone for your replys.. I am so scared now that if I get a leak or something goes wrong with my sleeve, my insurance will never cover it..

I am covered by my insurance through my employer, been working there for 9 years. It is a large organization in Arizona. Stil kind of shocked it was denied.

I don't think you should worry. A leak post-op would be a very different situation than the one described in the OP.

[Jersrose43 837]

Bs you can't appeal it

Of course you can. What state are you jn?

Appeal it to the insurance commissioner

State that insurance prohibited you appeal rights

Then clearly state why you need the surgery all he medical reasons why.

Do not refer to prior complications they paid for

State where and how you meet today's medical guidelines

Before you appeal request a copy of the medical policy so you can attach it. Make sure you meet every required point in it

[Beckyyb93 225]

I'm also a sleeve to bypass revision. My insurance covered my sleeve though and they just approved my bypass revision but my situation is a bit different than yours. Right after surgery I had a stricture and they dilated and sent me home promising me I'd feel better. That was in 2012 and I have not had any solid food since then at all. I've been hospitalized a dozen times, have had 6ish EGDs to dilate because I can't swallow. I'm now in the beginning of achalasia which can lead to esophageal cancer not to mention to debilitating spasms I have with every single thing I swallow. I still take liquid Vicodin to eat or drink anything, even the soft stuff like pudding. My revision was approved in less than a week partially because I'm sure my insurance is tired of covering all these long hospital stays.

I hope you can get your revision approved, I know better than most how much pain the bile from the sleeve can cause and it's not fun at all. I actually was warned about not going to Mexico in case of complications because they wouldn't cover work you had done down there. Hopefully you will appeal and try to get your current doctor to write a note stating the medical necessity because that's what my doc did. I'm getting married and my fiance's insurance doesn't cover anything bariatric, no complications involving wls, no medication for previous wls, etc. so I can't go on his insurance until I'm 100% healed and healthy after the revision. I hope that's not what your policy is stating because I was told that if we got married before I had the surgery nothing would be covered no matter what, no exceptions at all. If it covers wls in general you are more likely to be able to get the revision covered and I wish you tons of luck. I can keep you updated on my progress with the revision because I've heard it's a bit tough and I'd like to share my experiences with others to hopefully ease their mind about their upcoming procedures.

We will keep in touch, I'm sure all of us are wondering how you are doing so I'd love to hear from you!

[Butterflysecrets 20]

I am so sorry to hear that the insurance is being a butt! I had to have revision two days ago due to horrible reflux and strictures, plus my stomach became a "cascade stomach" again. I wish you the best of luck for your appeal.

[lulugirl 20]

I love reading all your comments, they give me some hope I can get the revision.

My insurance is telling me that there is no appeal process for this because I am being denied due to a pre deterimnation clause that states "I wasn't eligible for weight loss surgery under their guidelines, so they won't cover the revision to fix the reflux". i guess they feel the reflux is due to a complication. The coordinator did email me the link that shows this in the insurance guidelines.

I copied the wording in my original post, I am in Arizona. I was self pay in Mexico in July 2012 & have had reflux issues since.

[freezepop 13]

I am so sorry to hear that the insurance is being a butt! I had to have revision two days ago due to horrible reflux and strictures, plus my stomach became a "cascade stomach" again. I wish you the best of luck for your appeal.

How soon did you have these issues after your surgery?

[lulugirl 20]

I am so sorry to hear that the insurance is being a butt! I had to have revision two days ago due to horrible reflux and strictures, plus my stomach became a "cascade stomach" again. I wish you the best of luck for your appeal.

How soon did you have these issues after your surgery?

I started having these issues about 2 weeks after my sleeve surgery which was 2 years ago. I did get a phone call from the surgery cordinater last week. He said my case was discussed at a meeting with my doctor & she was going to contact the insurance company to discuss my case! So I am hoping that I will be able to have it done.

How are you feeling after your revision? Please keep me updated on your progress!

[Beckyyb93 225]

I just got the approval for my revision and I'm set for August 1st. I have a thread posted here where I'm going to document my whole story and experience. I have bad reflux, a stricture that won't heal and keeps getting more swollen and inflamed, and my esophagus is eroding at the site of the stricture. They told me if I don't revise soon I'm looking at Barret's which will eventually lead to esophageal cancer. My insurance company okay'd the surgery right away because my doctor is extremely worried about the future health of my esophagus. Oh, and the fact that I haven't been able to eat sold food since my sleeve in 2012. I'm kind of a rare case I guess but I'm Iron, Vitamin D and Protein deficient and I can't stay hydrated enough to keep from having bad kidney infections. Hopefully the surgery will go well for me and finally allow the stricture to heal, I can't wait to eat real food again!

Keep us updated, I'm hoping your insurance company will approve your surgery and I definitely know how reflux feels. Good luck!!

[swimbikerun 1,038]

I'm so glad!!! Let us know how things are doing.

[stacielynntate 88]

I just got the approval for my revision and I'm set for August 1st. I have a thread posted here where I'm going to document my whole story and experience. I have bad reflux, a stricture that won't heal and keeps getting more swollen and inflamed, and my esophagus is eroding at the site of the stricture. They told me if I don't revise soon I'm looking at Barret's which will eventually lead to esophageal cancer. My insurance company okay'd the surgery right away because my doctor is extremely worried about the future health of my esophagus. Oh, and the fact that I haven't been able to eat sold food since my sleeve in 2012. I'm kind of a rare case I guess but I'm Iron, Vitamin D and Protein deficient and I can't stay hydrated enough to keep from having bad kidney infections. Hopefully the surgery will go well for me and finally allow the stricture to heal, I can't wait to eat real food again! Keep us updated, I'm hoping your insurance company will approve your surgery and I definitely know how reflux feels. Good luck!!

Good luck to you.

Edited July 16, 2014 by stacielynntate

[lulugirl 20]

It has been a long time since I last posted. It is now 2017 & Im still suffering from reflux. Just had an EGD which shows esophagitis & reflux issues. I recently retired & now am only covered by Champ va insurance. My doctor is recommending surgery again & her office just called & said my insurance approved it. I am scheduled 7/11.

I am still worried that once I have this done Champ va will try not to pay it since I didn't go through the weight loss protocol back in 2012 when I went to Mexico.

I need the revision for reflux, not weight loss. I am so tired of everything I eat coming back up, also I'm not able to digest salad, veggies or fruit. Also lactose intolerant since my sleeve. I really hope this works.. I have kept my weight off, I'm 125lbs..