Revision Denied by BCBS of North Carolina

[Liv_94 4]

Hello everyone, I’ve gone through the long process of trying to get a revision surgery after gaining most of the weight back after having the sleeve in 2014. I’ve had mental health issues in the years following and also developed GERD and High blood pressure in the recent years since. The insurance company (BCBS of North Carolina) has been giving me issues from the start first saying that my surgeon wasn’t in network so they wouldn’t cover the surgery. Upon further investigation from my doctors office the real issue was them denying my claim for a revision because there was a lack of evidence showing that I followed proper diet and exercise after my first surgery. Has any experienced something similar? I have the two comorbidities and my bmi is currently 45 so I’m just kinda in shock they denied me especially without even informing me.

[catwoman7 10,933]

I don't know about this company or policy in particular, but many won't approve revisions for weight gain. Some, however, approve them if there are medical issues. Since you've had issues with GERD and high blood pressure, that *might* be enough for some companies -but again, not all companies approve revisions. I wonder if a doctor could have a peer-to-peer review with them. Although your current surgeon isn't in your network, so that might be an issue - is there a bariatric surgeon who's in your network that you could do a consultation with?

[Liv_94 4]

Well according to doctors office the insurance was trying to say he was out of network as an excuse. The hospital is in network and he’s employed by the hospital so he would be in network is what they told me. The doctors office has submitted information to my insurance company showing previous encounters notes with my past doctors so we’re waiting to hear back from that. They told me they will do a peer to peer if necessary. This just all stinks because my surgery is already scheduled and I am already on the liquid diet.

[SleeveToBypass2023 1,933]

I'm surprised the surgery was scheduled before having insurance approval. Is it possible to maybe find another doctor (I have BCBS of Illinois and they wouldn't allow the surgery to happen if the doctor AND the hospital weren't both in network) and see if they can get the surgery approved based on your new comorbidities.

[Liv_94 4]

27 minutes ago, SleeveDiva2022 said:

I'm surprised the surgery was scheduled before having insurance approval. Is it possible to maybe find another doctor (I have BCBS of Illinois and they wouldn't allow the surgery to happen if the doctor AND the hospital weren't both in network) and see if they can get the surgery approved based on your new comorbidities.

I know the insurance company is lying by saying the doctor is not in network because he already performed an endoscopy on me with no insurance issues. The doctors office accommodated me by giving me a surgery date because my employer was harassing me to give them information about when I’d be out and how long.

[KimA-GA 540]

2 hours ago, Liv_94 said:

Hello everyone, I’ve gone through the long process of trying to get a revision surgery after gaining most of the weight back after having the sleeve in 2014. I’ve had mental health issues in the years following and also developed GERD and High blood pressure in the recent years since. The insurance company (BCBS of North Carolina) has been giving me issues from the start first saying that my surgeon wasn’t in network so they wouldn’t cover the surgery. Upon further investigation from my doctors office the real issue was them denying my claim for a revision because there was a lack of evidence showing that I followed proper diet and exercise after my first surgery. Has any experienced something similar? I have the two comorbidities and my bmi is currently 45 so I’m just kinda in shock they denied me especially without even informing me.

are you doing any weight management appointments with a dr or nutritionalist? if that’s their denial reason, then it won’t hurt for you to do it while it gets sorted out..

may be able to manage GERD better in the meantime if a nutritionist who understands consults with you..

drs offices deal with denials all the time and are good at sorting it out, especially if you do everything you can to speed it up on your end

[Liv_94 4]

8 hours ago, KimA-GA said:

are you doing any weight management appointments with a dr or nutritionalist? if that’s their denial reason, then it won’t hurt for you to do it while it gets sorted out..

may be able to manage GERD better in the meantime if a nutritionist who understands consults with you..

drs offices deal with denials all the time and are good at sorting it out, especially if you do everything you can to speed it up on your end

I did several appointments with the nutritionist before they submitted and that was another thing they tried to say I didn’t do so I’m not really sure what’s going on.

[Ambular 4]

On 12/9/2022 at 5:50 PM, Liv_94 said:

I did several appointments with the nutritionist before they submitted and that was another thing they tried to say I didn’t do so I’m not really sure what’s going on.

hello there! Any updates? I"m in the same situation with BCBSNC...wondering what happened. I'm in the middle of proving to them that I followed instructions...

[Ambular 4]

hello there! Any updates? I"m in the same situation with BCBSNC...wondering what happened. I'm in the middle of proving to them that I followed instructions...

[Liv_94 4]

15 minutes ago, Ambular said:

hello there! Any updates? I"m in the same situation with BCBSNC...wondering what happened. I'm in the middle of proving to them that I followed instructions...

My doctor ended up doing a peer to peer with the insurance company and then it was approved and I had it as planned!

[Ambular 4]

47 minutes ago, Liv_94 said:

My doctor ended up doing a peer to peer with the insurance company and then it was approved and I had it as planned!

Congrats!! I'm so happy for you! how has your journey been with revision?

[Liv_94 4]

8 minutes ago, Ambular said:

Congrats!! I'm so happy for you! how has your journey been with revision?

Thank you! So far really well, on my surgery day in Dec 2022 I started at 265 and I’m currently down to 195

[Ambular 4]

1 hour ago, Liv_94 said:

Thank you! So far really well, on my surgery day in Dec 2022 I started at 265 and I’m currently down to 195

Wow that’s amazing progress! I’m so thankful you responded back to me! Sounds like you’re having a happy ending. Any advice on the revision? Anything you would change or prepare for? What would you tell yourself before the surgery?

[Liv_94 4]

8 minutes ago, Ambular said:

Wow that’s amazing progress! I’m so thankful you responded back to me! Sounds like you’re having a happy ending. Any advice on the revision? Anything you would change or prepare for? What would you tell yourself before the surgery?

I would definitely say for the first few weeks don’t be discouraged! When I got home from the hospital I was 10 lbs heavier and it took some time to get that off and actually start losing. Also for myself I thought I could still eat at the speed I used to which was a big mistake that I’m still working on even now! I need to chew throughly or my stomach will definitely hurt. I’ve gotten better though because my first few months I would either throw things up or get the foamies. Lastly I can still tolerate things like sugar in small amounts but you’ll quickly learn that it really just depends on what it is. I’ve eaten a donut with no problem but then a few weeks ago I had a small bowl of Cinnamon Toast Crunch and was in the bathroom 3 times in an hour. I do mostly sugar free things but occasionally I’ll have something with regular sugar so it’s good that I know what I can and can’t tolerate.

[Ambular 4]

7 hours ago, Liv_94 said:

I would definitely say for the first few weeks don’t be discouraged! When I got home from the hospital I was 10 lbs heavier and it took some time to get that off and actually start losing. Also for myself I thought I could still eat at the speed I used to which was a big mistake that I’m still working on even now! I need to chew throughly or my stomach will definitely hurt. I’ve gotten better though because my first few months I would either throw things up or get the foamies. Lastly I can still tolerate things like sugar in small amounts but you’ll quickly learn that it really just depends on what it is. I’ve eaten a donut with no problem but then a few weeks ago I had a small bowl of Cinnamon Toast Crunch and was in the bathroom 3 times in an hour. I do mostly sugar free things but occasionally I’ll have something with regular sugar so it’s good that I know what I can and can’t tolerate.

Thank you for the insight! I definitely need to slow my eating down too - what is foamies? I dont think I’ve experienced that with sleeve.