So i am working with a surgeon on getting the overstitch procedure done. I had surgery in 2006 at 292 and only lost about 50 pounds. I am now at 282 and my EGD tomorrow. Has anyone had experience with the approval process with a revision. I have Blue Coss of California insurance. I definitely have 6 months of documented weight loss attemps over the past few years 3 months was a medical weight loss place and immediately following 3 months with my doctor.

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I don't have tons to offer on the recert process, but am sort of in a similar place. I have Aetna PPO. Had RNY in 1992 (gulp) dropped 100#s, regained most and tried to have a revision 8 years after initial and went through ALL the hoops only for insurance to deny saying I didn't have any comorbidities. I'm hoping that was a LONG time go and things have changed since.

I went to surgeon in October (had to view online webinar or go to in person session first). Even for a revision the nurse who does pre-certs said Aetna would require me to do the 3 month diet/multi disciplinary approach. Had to meet with dietitian x 3 1 1:1 sesssion and 2 group sessions-- the group sessions were pretty lame), exercise specialist (not super helpful), get a pysch eval and met with physician a couple times. I had an EGD and upper GI done. Upper GI showed my stomach was near normal capacity, stoma stretched out and small intestines enlarged-- I didn't need the test to tell me that I can tell by the quantity of food I can eat. My insurance actually covered all the pre-op visits with no co-pay except for the psych eval. If I went through their office it was going to be $300 cash. I asked about using a provider in my plan, they made a suggestion and I did my psych eval with her for my regular behavioral health co-pay. She is a eating disorder specialist (all kinds) and I actually opted to end up continuing sessions with her for the time being. It's covered as part of my behavioral health benefit. If I can't figure out what is driving me to eat so much and eat through my surgery having another won't do much good for the long term.

I had everything done as of the end of January. The office could have submitted as of Jan 20th but I guess forgot and I didn't think to call to remind. I was in yesterday meeting with their bariatrician and asked and they said they would submit for pre-cert right away. It takes 2-3 weeks. The gal in the office said she's 80-85% sure it will be approved. Since I went through all this years ago and was rejected I'm super anxious. I read through my insurer's coverage documentation for WLS before going to see the doctor. One of the options he recommended is not covered by my insurer because they consider it experimental-- even though it is the least expensive and least invasive. So that is off the table. He said revisions can have A LOT of complications, so I need to think long and hard about revision surgery. If it's approved...I'm going for it.

In addition to continuing with seeing the counselor I also opted to see the bariatrician they have in their medical group (they are affiliated / part of the large health system in our area) just yesterday. I figured if surgery isn't approved, I need a plan B and even if it is I need as much concerted effort/focus on trying to make this work as possible. The counselor has suggested medication with or without surgery as an adjunct after our third session based on my eating patterns/habits. The bariatrician prescribed Qsymia which I started today (I'd already had a batter of labs, tests, etc. so knew I was healthy enough to start). She said she has a lot of WLS patients who use medications in addition to or after surgery once they plateau or if they start to regain. She listed out all the med options and I chose this one in particular. It was also the one she said her patients have the best results and least side effects with. She also had me start a food diary and replacing one meal per day with protein shake and gave me an exercise plan-- so not just the script for meds. My insurance won't cover but got a manufacturer's card to help reduce the price. I did find in their coverage determination documentation IF I had tried to lose with for months and was not successful then they would have covered. I don't want to wait around... She said the variety of medications provide a nice arsenal of adjunct support and she has moved patients between different medications if they build up a tolerance. In the past I've responded really well to phentermine and this has that in it, so I'm hopeful.

Before hooking up with the bariatric group at the health system I couldn't find a counselor who specialized in eating disorders for adults who are overweight and finding a physician to prescribe the newer WL meds was impossible (I tried both independently). SO, if nothing else, the process has helped me connect with those resources. While I do feel a little like they "herd" patients through the process in some ways (group dietitian visits that weren't super great) they really seem to know how to manage the process.

I know I overshared-- more than what you asked about-- but thought some of this might be of use since we are in a similar spot having regained after our first surgery.

Curious to hear from anyone else AND how your process shakes out.

Best of luck to you!

Jolie

Hi Jolie, may i ask if the procedure they deemed experimental was the band over the RNY? My doctor just submitted me for the overstitch procedure today.

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On 2/22/2018 at 8:23 PM, nickie2524 said:

Hi Jolie, may i ask if the procedure they deemed experimental was the band over the RNY? My doctor just submitted me for the overstitch procedure today.

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Hi Nickie- Belowis everything they identify as experimental or investigational per their policy bulletin. Here is the link to the original document:

http://www.aetna.com/cpb/medical/data/100_199/0157.html

It looks like band over bypass is on the list. My surgeon had suggested as one of three options to do an endoscopic suturing procedure. He said less risk, less cost, no hospital time but the results were also questionable and it had to be either/or. So if the endoscopic option didn't work, then I couldn't go back and do the laprascropic procedure later.

Good news, I found out surgery was approved. Now I just need to decide whether to move forward or not. He was very keen on making sure I understand the increased risk and decreased opportunity for weight loss outcomes. Hence my full court press with counseling and weight loss meds as adjuncts.

Let me know how yours turns out!!Experimental and Investigational Bariatric Surgical Procedures:

Aetna considers each of the following procedures experimental and investigational because the peer-reviewed medical literature shows them to be either unsafe or inadequately studied:

• AspireAssist aspiration therapy
• “Band over bypass” or LASGB revision of prior Roux-en-Y gastric bypass
• "Band over sleeve" or LASGB revision of prior sleeve gastrectomy
• Bariatric surgery as a treatment for idiopathic intracranial hypertension
• Bariatric surgery as a treatment for infertility
• Bariatric surgery as a treatment for type-2 diabetes in persons with a BMI less than 35
• Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass as a treatment of gastro-esophageal reflux disease (GERD)
• Gastric bypass as a treatment for gastroparesis
• Gastroplasty, more commonly known as “stomach stapling” (see below for clarification from vertical band gastroplasty)
• Laparoscopic gastric plication (also known as laparoscopic greater curvature plication [LGCP]), with or without gastric banding
• LASGB, RYGB, and BPD/DS procedures not meeting the medical necessity criteria above
• Liposuction (suction-assisted lipectomy; ultrasonic assisted liposuction)
• Loop gastric bypass
• Mini gastric bypass
• Natural orifice transoral endoscopic surgery (NOTES) techniques for bariatric surgery including, but may not be limited to, the following:
  
  • Gastrointestinal liners (endoscopic duodenal-jejunal bypass, endoscopic gastrointestinal bypass devices; e.g., EndoBarrier and the ValenTx Endo Bypass System); or
  • Intragastric balloon (e.g., the ReShape Integrated Dual Balloon System); or
  • Restorative obesity surgery, endoluminal (ROSE) procedure for the treatment of weight regain after gastric bypass surgery; or
  • Transoral gastroplasty (TG) (vertical sutured gastroplasty; endoluminal vertical gastroplasty; endoscopic sleeve gastroplasty); or
  • Use of any endoscopic closure device (Over the Scope clip [OTSC] system set, Apollo OverStitch endoscopic suturing system, StomaphyX endoluminal fastener and delivery system) in conjunction with NOTES;
    
• Open adjustable gastric banding
• Prophylactic mesh placement for prevention of incisional hernia after open bariatric surgery
• Roux-en-Y gastric bypass as a treatment for gastroesophageal reflux in non-obese persons
• Sclerotherapy for the treatment of dilated gastrojejunostomy following bariatric surgery
• Silastic ring vertical gastric bypass (Fobi pouch)
• Vagus nerve blocking (e.g., the VBLOC device, also known as the Maestro Implant or the Maestro Rechargeable System)
• VBG, except in limited circumstances noted above.

I don't have tons to offer on the recert process, but am sort of in a similar place. I have Aetna PPO. Had RNY in 1992 (gulp) dropped 100#s, regained most and tried to have a revision 8 years after initial and went through ALL the hoops only for insurance to deny saying I didn't have any comorbidities. I'm hoping that was a LONG time go and things have changed since.
I went to surgeon in October (had to view online webinar or go to in person session first). Even for a revision the nurse who does pre-certs said Aetna would require me to do the 3 month diet/multi disciplinary approach. Had to meet with dietitian x 3 1 1:1 sesssion and 2 group sessions-- the group sessions were pretty lame), exercise specialist (not super helpful), get a pysch eval and met with physician a couple times. I had an EGD and upper GI done. Upper GI showed my stomach was near normal capacity, stoma stretched out and small intestines enlarged-- I didn't need the test to tell me that I can tell by the quantity of food I can eat. My insurance actually covered all the pre-op visits with no co-pay except for the psych eval. If I went through their office it was going to be $300 cash. I asked about using a provider in my plan, they made a suggestion and I did my psych eval with her for my regular behavioral health co-pay. She is a eating disorder specialist (all kinds) and I actually opted to end up continuing sessions with her for the time being. It's covered as part of my behavioral health benefit. If I can't figure out what is driving me to eat so much and eat through my surgery having another won't do much good for the long term.
I had everything done as of the end of January. The office could have submitted as of Jan 20th but I guess forgot and I didn't think to call to remind. I was in yesterday meeting with their bariatrician and asked and they said they would submit for pre-cert right away. It takes 2-3 weeks. The gal in the office said she's 80-85% sure it will be approved. Since I went through all this years ago and was rejected I'm super anxious. I read through my insurer's coverage documentation for WLS before going to see the doctor. One of the options he recommended is not covered by my insurer because they consider it experimental-- even though it is the least expensive and least invasive. So that is off the table. He said revisions can have A LOT of complications, so I need to think long and hard about revision surgery. If it's approved...I'm going for it.
In addition to continuing with seeing the counselor I also opted to see the bariatrician they have in their medical group (they are affiliated / part of the large health system in our area) just yesterday. I figured if surgery isn't approved, I need a plan B and even if it is I need as much concerted effort/focus on trying to make this work as possible. The counselor has suggested medication with or without surgery as an adjunct after our third session based on my eating patterns/habits. The bariatrician prescribed Qsymia which I started today (I'd already had a batter of labs, tests, etc. so knew I was healthy enough to start). She said she has a lot of WLS patients who use medications in addition to or after surgery once they plateau or if they start to regain. She listed out all the med options and I chose this one in particular. It was also the one she said her patients have the best results and least side effects with. She also had me start a food diary and replacing one meal per day with protein shake and gave me an exercise plan-- so not just the script for meds. My insurance won't cover but got a manufacturer's card to help reduce the price. I did find in their coverage determination documentation IF I had tried to lose with for months and was not successful then they would have covered. I don't want to wait around... She said the variety of medications provide a nice arsenal of adjunct support and she has moved patients between different medications if they build up a tolerance. In the past I've responded really well to phentermine and this has that in it, so I'm hopeful.
Before hooking up with the bariatric group at the health system I couldn't find a counselor who specialized in eating disorders for adults who are overweight and finding a physician to prescribe the newer WL meds was impossible (I tried both independently). SO, if nothing else, the process has helped me connect with those resources. While I do feel a little like they "herd" patients through the process in some ways (group dietitian visits that weren't super great) they really seem to know how to manage the process.
I know I overshared-- more than what you asked about-- but thought some of this might be of use since we are in a similar spot having regained after our first surgery.
Curious to hear from anyone else AND how your process shakes out.
Best of luck to you!
Jolie

I was approved surgery scheduled 3/20 for overstitch.

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