Lap-Band to Bypass Revision w/Insurance

[Lauren87 7]

Hi, All:

I was banded in 2009 and never had much success with it. Any time I got restriction, it came with a lot of heartburn (which manifested itself as nausea). I also struggled with a lot of food intolerance. Eventually, because my insurance switched and I have a written exclusion regarding bariatric surgery, I had the band mostly unfilled due to too much restriction and cost.

At any rate, in January, my health insurance plan will now include bariatric surgery, although it’s unclear as to what language looks like regarding revisions. One concern I have is how to make a case to the insurance company deeming the revision medically necessary. I have had many EGDs, which showed mild irritation in my esophagus, but nothing extreme. Grandest, it’s been almost 10 years since anyone’s looked at the band and who knows what the current state of affairs is—I will have an evaluation once my insurance kicks in.

Does anyone have any suggestions or tips in dealing with insurance companies covering revision when severe symptoms, slippage, erosion, etc isn’t present?

[Msbosse 29]

I was banded in 2012 and now I am doing a revision to the sleeve with insurance. I have Aetna and they pretty much approve anything. I did have a revision on the band in 2015 due to acid reflux and my gallbladder. After my gallbladder was removed I started to gain the weight I lost back and the band gives me horrible pain in the port. If possible I would see if your insurance shows the clinical information on what they approve for certain procedures and what the requirements are to get approved. Aetna has it where you just call them and tell them what you are trying to do and they give you a clinical id that tells you what you need to be approved. Based on that information I should be approved soon for my revision to the sleeve. I would just check with the insurance company and ask. I hope this helps.

[Orchids&Dragons 9,047]

Your surgeon's office will have the best guidance. They go through the hoops all the time. It's not your problem to figure out.

[Lauren87 7]

Thank you both, Orchids&Dragons and MsBosse! I appreciate your insight. I really have no clue what the policy will look like until open enrollment since it was previously a written exclusion and this is the first time they've covered it. I'm a state employee with group health insurance/uniform benefits, so I'll be curious to see if each plan will have the same language regarding revision, or if they'll be different. I spoke to a nurse with the bariatric program last week and felt a little defeated because I felt like she was pushing towards the idea that if there's nothing wrong with the band, I'm SOL. Now, whether or not that is true, I don't know. That may just be me being hyper-sensitive.

Again, I appreciate the feedback from you both! Once the plans are out, I'll start digging, calling, and consulting. Thank you!

[SorryNameTaken 85]

I am revising from band to bypass on October 24. Unfortunately, despite insane nausea, heartburn, the pain with eating, I had nothing that looked to be an emergency, so I had to start back from the beginning with weigh-ins and nutrition visits. Without anything showing the band had to come out in an emergency situation, insurance would not cover the revision.

I hope you have better luck, but just be prepared that it might not happen right away! It's a bummer, but I'm certain it will be worth not dealing with the band anymore 😃

[JohnnyMadison 15]

I'm in Wisconsin and can only speak to my experience for VSG>RNY revision insurance approval. I had really bad GERD and my endoscopies showed Barrett's. So Blue Shield (my employer is in CA) approved it immediately for GERD and did not impose any pre-operative requirements such as monitored weight loss, etc. So my recommendation would be to pursue it for complications and not WLS if you want a quick approval.

[Lauren87 7]

Thanks, JohnnyMadison and SorryNameTaken!

This is going to be an interesting journey--since my last post, the certificate of medical coverage came out for our plans (local government employee, uniform benefits... a blessing and curse!) and they are covering bariatric surgery and the only requirement is to have a BMI over 35 and to be considered medically necessary. So, this is either going to be really easy or really hard, but I won't know what kind of approach we're taking until I can start the program. There is no language in there regarding revisions, which does give me a pause, but if I meet the requirements and they prior-authorize the work, then I assume we're good to go. That's what I'm hoping, anyway.

P.S. JohnnyMadison, nice to see another Wisconsinite present--I presume you're also in Madison? Small world? Did you go through UW for your revision? I have only heard positive things!

Edited October 11, 2019 by Lauren87
Type-o

[JohnnyMadison 15]

29 minutes ago, Lauren87 said:

Thanks, JohnnyMadison and SorryNameTaken!

This is going to be an interesting journey--since my last post, the certificate of medical coverage came out for our plans (local government employee, uniform benefits... a blessing and curse!) and they are covering bariatric surgery and the only requirement is to have a BMI over 35 and to be considered medically necessary. So, this is either going to be really easy or really hard, but I won't know what kind of approach we're taking until I can start the program. There is no language in there regarding revisions, which does give me a pause, but if I meet the requirements and they prior-authorize the work, then I assume we're good to go. That's what I'm hoping, anyway.

P.S. JohnnyMadison, nice to see another Wisconsinite present--I presume you're also in Madison? Small world? Did you go through UW for your revision? I have only heard positive things!

Yes, I am in Madison and getting revision done at UW! I was scheduled 11/11 but am selling old house on 11/1 and closing on new house on 12/2 and didn't want to do it while living in in a corporate apartment, nor did I want to move into new house with possible post-op restrictions. So I rescheduled to 12/16.

The code on my pre-authorization paperwork for the procedure is just for RNY. It doesn't list revision and when I look up the CPT it just describes the procedure. So perhaps revision is a modifier to the original code so that's why no language about it. With your plan if you meet the requirements it looks pretty good. My plan had a comorbidity requirement but I also didn't meet the 35 or 30 BMI so maybe that's why they did it as a non-bariatric reason, even though I am obviously a bariatric patient.

Good luck! I am going through Dr. Greenberg. The facility is just a few miles from both of my houses so I am grateful for all that. I had my original VSG done in Mexico because work didn't have WLS coverage at the time. All of the pre-op nutritional sessions and all that are annoying but at least I don't have to do the supervised diet like most of the people having surgery in my groups. Being on a restricted diet with my original stomach was torture. It is much easier for me with a sleeve and ironically I don't have to do it.

[JRT Mom 920]

I have to get my band removed and have opted to get a bypass the same time the band is removed. I have NO fill in my band and I still get food hung constantly and my surgeon says it's not a matter of "if" my stomach totally occluded but a matter of "when".

When I got the band 10 years ago United Healthcare paid for the first one. Now I'm on Medicare and the patient coordinator at the first office I consulted with said that Medicare had a strict rule that once you've had a procedure Medicare wouldn't pay for a second one. Well the doctor I'm seeing now said that was ridiculous since Medicare didn't even pay for the first surgery, and now I have to have the band removed through no fault of my own. They are making me meet Medicare's criteria of a three month supervised diet, and the surgeon is hoping I won't occlude before this time is done. I also have to have a BMI of 35 with a comorbidity but since last year I've developed high blood pressure and some maturity onset diabetes and with the weight gain from the failed band no problems there...

I just would like something in writing that Medicare WILL cover it...I'd hate to be denied after the fact an be stuck with that bill!

[Lauren87 7]

On 10/11/2019 at 4:02 PM, JohnnyMadison said:

Yes, I am in Madison and getting revision done at UW! I was scheduled 11/11 but am selling old house on 11/1 and closing on new house on 12/2 and didn't want to do it while living in in a corporate apartment, nor did I want to move into new house with possible post-op restrictions. So I rescheduled to 12/16.

The code on my pre-authorization paperwork for the procedure is just for RNY. It doesn't list revision and when I look up the CPT it just describes the procedure. So perhaps revision is a modifier to the original code so that's why no language about it. With your plan if you meet the requirements it looks pretty good. My plan had a comorbidity requirement but I also didn't meet the 35 or 30 BMI so maybe that's why they did it as a non-bariatric reason, even though I am obviously a bariatric patient.

Good luck! I am going through Dr. Greenberg. The facility is just a few miles from both of my houses so I am grateful for all that. I had my original VSG done in Mexico because work didn't have WLS coverage at the time. All of the pre-op nutritional sessions and all that are annoying but at least I don't have to do the supervised diet like most of the people having surgery in my groups. Being on a restricted diet with my original stomach was torture. It is much easier for me with a sleeve and ironically I don't have to do it. 

I totally get not wanting to fuss with selling and moving... and recovering! I'm sure you'll be thankful when you can cross all three things off of your list.

I haven't met with the folks from UW yet because my insurance (ETF supplied) presently has a written exclusion on bariatric surgery, so anything would be self-pay and I work in local government, so I'm waiting until January 1 when the new policy kicks in. However, given how lax the requirements are, I'm hoping to have surgery within the calendar year before the change their minds and make surgery nearly impossible (again). I'm not sure exactly what the road to revision will look like, the nurse I spoke to just said that it's a little bit of a different path, but I imagine I will need to do the pre-op diet simply because the Band wasn't a great tool and I'm back to where I started. So, in that respect, I'm thankful that I'll have to go through the classes again--it might not be new info, but it will be good for me to treat it like a new experience (and I suppose it is!).

Best of luck on the revision, I'll be anxious to hear how everything goes for you once it's all said and done!

[Lauren87 7]

On 10/11/2019 at 11:10 PM, JRT Mom said:

I have to get my band removed and have opted to get a bypass the same time the band is removed. I have NO fill in my band and I still get food hung constantly and my surgeon says it's not a matter of "if" my stomach totally occluded but a matter of "when".

When I got the band 10 years ago United Healthcare paid for the first one. Now I'm on Medicare and the patient coordinator at the first office I consulted with said that Medicare had a strict rule that once you've had a procedure Medicare wouldn't pay for a second one. Well the doctor I'm seeing now said that was ridiculous since Medicare didn't even pay for the first surgery, and now I have to have the band removed through no fault of my own. They are making me meet Medicare's criteria of a three month supervised diet, and the surgeon is hoping I won't occlude before this time is done. I also have to have a BMI of 35 with a comorbidity but since last year I've developed high blood pressure and some maturity onset diabetes and with the weight gain from the failed band no problems there...

I just would like something in writing that Medicare WILL cover it...I'd hate to be denied after the fact an be stuck with that bill! 

I can understand why--surgery is very expensive! I have done a lot of research on health insurance plans and I have seen a few that have the strict "one surgery per lifetime" clause, which as your surgeon says, is ridiculous. I can sort of understand the rationale if the plan was the same, but because they're not, they have no reason to complain. Insurance can be so frustrating!

Having to go through the supervised diet again is such a pain, but I'm glad to hear it's 3 months and not 6. I really wish there was more acceptance and understanding from the insurance companies (I know, I know, never going to happen)... you're in a hard place and it's absurd to think you're supposed to pay for it on your own. After I had my Lap-band surgery, I had several health insurance plans with written exclusions on baratric surgery and that is a large reason that I haven't had follow-up done in years--I can't pay for it out of pocket. It was a per-existing condition I came to the plan with!

I'm sure your program manager knows this, but I'd be anxious to get a pre-authorization letter for the surgery, then you know they're on the hook for covering it!

[mzchyll924 1]

I am a lap band to sleeve gastrectomy. My surgery is scheduled for 11/22/19. I have a nasty slip with my babe which I'm convinced happened after my gallbladder removal sx. I gained haha of what I lost after the gallbladder sx. Fortunately I have Tricare and all will be covered. I know a young lady who when to Mexico to Pompeii Bariatric. They seem to be reasonable and may work with you. Check them out. Can't hurt. You need to get that thing out if nothing more.

Sent from my SM-N960U using BariatricPal mobile app

[Lauren87 7]

3 hours ago, mzchyll924 said:

I am a lap band to sleeve gastrectomy. My surgery is scheduled for 11/22/19. I have a nasty slip with my babe which I'm convinced happened after my gallbladder removal sx. I gained haha of what I lost after the gallbladder sx. Fortunately I have Tricare and all will be covered. I know a young lady who when to Mexico to Pompeii Bariatric. They seem to be reasonable and may work with you. Check them out. Can't hurt. You need to get that thing out if nothing more.

Thanks, mzchyll924! At this point, self-pay is off the table, but now that I've seen the certificate of coverage for my plan next year, I'm really hoping it's a pretty easy process given the requirements. I'm so glad to hear all of your revision will be covered!