Denied Revision - Insurance says not medically necessary

[Carrie P 24]

I just wondered if anyone has had anything like this happen. I have BCBS NC insurance. I'll give you the Reader's Digest version of my history.

Lap Band in 2008. My surgery weight was 258 and I lost down to 227. That's it. I never got any further no matter what I did. I got pregnant, gained weight, and then have failed to lose it. I started eating slider foods and gained a little more weight. Then, the heartburn kicked in. It led me back to my doctor even though I was ashamed of the weight I'd regained. I had an Xray, an EGD, and a barium swallow. My band is in the right place. It hasn't slipped. No H. Pylori. They didn't see any reflux on the barium swallow. I beg to differ since I was hurting pretty badly and having that awful left shoulder pain after the procedure. Anyway, my surgeon has recommended that I get a revision to gastric bypass. Today the insurance company said they wouldn't cover it because it wasn't medically necessary. They also told me to have my surgeon call so they can do a peer review.

Any success stories for something like this?

[Hammer_Down 631]

My $.02:

Find the reason the restriction of the band didn't help with weight loss. There's a great deal of personal commitment required to make any WLS surgery work, as it is just a tool and not a miracle. Eating habits must be changed. Mental changes around food must be addressed by you. There are many successful lap band patients on this site, reach out and find out what they did differently and how they successfully lost weight.

Secondly, barring some medical issue like a slipped band, erosion etc I can understand the telictannce to pay for another procedure. The sleeve is not magic. Any and all weight loss will come from careful planning, following dietary guidelines closely and addressing your relationship with food. It's not much different from a band, it just removes some of the possible negative outcomes like slipping, erosion, adjusting fills, etc.

The work is still up to you. You admit that you aren't following a weight loss plan now, so why would that be any different with the sleeve?

If you are hell bent on getting it done, i would suggest going to Mexico for a revision and self paying.

[Carrie P 24]

Thank you for your insight. However, I had been following the diet. In fact, with a few exceptions, I'm still eating like I would with the band. My band is empty right now. I've been on Prilosec about 2 months now and am feeling better; but I'm also more hungry. What I didn't say was every time they try to add Fluid to the band now, I get heartburn...even though the barium swallow didn't show reflux. It did show irritation near the pyloric valve consistent with my symptoms though. The slider foods started after I started having heartburn when I would try to eat solid Protein.So, I started eating more cottage cheese, tuna with mayo, etc.

I'm also wanting to revise to gastric bypass. I have been on the struggling lap band board as well as both the sleeve and bypass revision boards. I'm just asking about insurance.

[Aggiemae 739]

Insurance that covers WLS covers one procedure. You and is functioning. Your only option is getting it filled. if you haven't already, ask your Dr to check your thyroid and/or do a complete metabolic panel.

[Carrie P 24]

Insurance that covers WLS covers one procedure. You and is functioning. Your only option is getting it filled. if you haven't already, ask your Dr to check your thyroid and/or do a complete metabolic panel.

Thank you. We already did that. My surgeon just called me and he's getting on the phone with insurance. He said that I'm one of those people that the band just didn't work for. My insurance covers revision in that instance as well. He said he's confident that he can get the decision overturned. I'm crossing my fingers.

[mskay01 0]

I was told when I went in for the Lap-Band procedure over 10 years ago that the weight limit was 200 or you won't be successful...

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[Carrie P 24]

Update: My surgeon did a peer-to-peer review and my insurance was approved! Yay!

Whatever the reason, the Lap Band just didn't work for me. However, it has worked for a lot of people. I wish it had, but it is what it is. :-)