Waiting on revision approval - BCBS

[gebbiabn 34]

I am definitely feeling a bit discouraged right now. I've had the gastric band since January 2011. Since the very beginning, I've had the throwing up/regurgitating. It doesn't matter what I eat. If I have any restriction at all, I'm throwing up 2-3 times per day. My current surgeon (not the one who did the surgery) also said according to the X-ray, my band is slightly higher than it should be, but not technically "out of place". They had to loosen my band, and since then (2 months ago), I've gained about 15-20lbs back. My HW 300, SW 290, LW 220, and CW 270. My surgeon said he'd do everything he can to help me. I've done the nutrition class (again) and the psych evaluation. They submitted to insurance yesterday, and she said I should hear back within 2-3 weeks if I'm approved or not.

But I've been reading A LOT of stories of people being denied for revision unless there is a serious complication with the band. I have BCBSNC. The insurance company that originally paid for my gastric band surgery was Tricare Prime, by Dr. William Richards in Mobile, Alabama.

[ar1kah12 3]

My friends daughter had to go through a similar process and it took her a year to get through her appeal but she was able to do so and I believe she went with the sleeve. She said it's worth the fight though. She had tricare prime for both wls

[gebbiabn 34]

The first time they sent it in, it was denied. But my surgeon did a peer to peer review two weeks later and got me an approval. I got the call October 30th my surgery date is December 7th!!

[ar1kah12 3]

That is amazing!!! Yaaaay!

[redhed 0]

I would love to know more about your appeal. I also have BCBS and was denied the conversion surgery. They look at it as two separate surgeries and denied each one for different reasons.

I've been holding off on my appeal because I don't know that the "magic words" are to change their minds.

[gebbiabn 34]

@@redhed - After my denial, my surgeon skipped the appeal process and requested a peer-to-peer review immediately. It took about 1.5 weeks for the review to take place. But he got an approval from that. He got the answer the next morning actually, and I had surgery a month later.

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[redhed 0]

I asked my doctor's office about the peer-to-peer and was told that the BCBS didn't request it! Of course I responded that I thought it was the responsibility of the doctor to request it. I didn't know that existed until I read it on here and now her office is acting like it's too late. I think my best bet might be to start seeing another doctor and pursue an appeal. The issue now is finding one with a good track record of winning appeals!

[gebbiabn 34]

It was something my surgeon requested. Because he said he knew that if we appealed it, it would just get denied again. He felt our best option for approval was with a peer to peer review. Don't give up! And find you a doctor that will fight for you!!

Sent from my iPhone using the BariatricPal App