Revision Denied by BCBS of North Carolina

[Liv_94 4]

1 hour ago, Ambular said:

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.

I did not experience it with the sleeve either only when I had the bypass. It’s like being on the verge of throwing up, it’s kinda like when a baby spits up. Not pleasant at all and the only thing that really helps that for me is actually throwing up.

[Ambular 4]

2 hours ago, Liv_94 said:

I did not experience it with the sleeve either only when I had the bypass. It’s like being on the verge of throwing up, it’s kinda like when a baby spits up. Not pleasant at all and the only thing that really helps that for me is actually throwing up.

That is really good to know. My particular situation is I had a baby eariler this year and gained 80lbs from pregnany. I"m 6months post partum and still breastfeeding so that makes me super nervous but docs say I should get the revision.

[Liv_94 4]

7 hours ago, Ambular said:

That is really good to know. My particular situation is I had a baby eariler this year and gained 80lbs from pregnany. I"m 6months post partum and still breastfeeding so that makes me super nervous but docs say I should get the revision.

For me I think I should’ve gotten a bypass in the first place but my pcp said I was so young and the sleeve was good so I just went along with it. At first I had no intention to get a revision even though I had gained almost all the weight back but I’m glad I did and I have no regrets.

[Ambular 4]

On 10/19/2023 at 4:28 PM, Liv_94 said:

For me I think I should’ve gotten a bypass in the first place but my pcp said I was so young and the sleeve was good so I just went along with it. At first I had no intention to get a revision even though I had gained almost all the weight back but I’m glad I did and I have no regrets.

BTW this is what BSBCNC said to me. They just seem like they auto deny and don't even check records as we have been so compliant and have plenty of evidence. It sucks because I don't even live in NC - I only have this because I work remoltely for a company in NC and live in CA..

We are gearing up for the peer 2 peer now but here is what was said:

Revision of a primary bariatric surgery to a gastric bypass is covered when you meet one of the following scenarios:

(1) You have regained weight after your original surgery. In this case, you must continue to meet basic criteria for weight loss surgery, including nutritional and psychological assessments, and you must have documentation of compliance visits (including compliance with nutrition and exercise recommendations) after your previous weight loss surgery

(2) You have severe reflux disease that has not been responsive to optimal medical management (maximum medication therapy, diet alteration with the assistance with a nutritionist, and change in activity and positioning). Failure of medical management must be documented, and studies to support persistent untreatable reflux must be submitted.

Review of your provided records reveals that you have regained weight after your previous surgery; however, we have not been provided with compliance records from your prior post-surgical visits. Additionally, it does not appear you have undergone optimal medical management for your reflux or that studies show severe signs of reflux.

[Liv_94 4]

2 hours ago, Ambular said:

BTW this is what BSBCNC said to me. They just seem like they auto deny and don't even check records as we have been so compliant and have plenty of evidence. It sucks because I don't even live in NC - I only have this because I work remoltely for a company in NC and live in CA..

We are gearing up for the peer 2 peer now but here is what was said:

Revision of a primary bariatric surgery to a gastric bypass is covered when you meet one of the following scenarios:

(1) You have regained weight after your original surgery. In this case, you must continue to meet basic criteria for weight loss surgery, including nutritional and psychological assessments, and you must have documentation of compliance visits (including compliance with nutrition and exercise recommendations) after your previous weight loss surgery

(2) You have severe reflux disease that has not been responsive to optimal medical management (maximum medication therapy, diet alteration with the assistance with a nutritionist, and change in activity and positioning). Failure of medical management must be documented, and studies to support persistent untreatable reflux must be submitted.

Review of your provided records reveals that you have regained weight after your previous surgery; however, we have not been provided with compliance records from your prior post-surgical visits. Additionally, it does not appear you have undergone optimal medical management for your reflux or that studies show severe signs of reflux.

Wow that’s more detailed than what they said to me. I don’t live in NC either my company is based in NC as well and this was the letter they sent me

[Ambular 4]

On 10/22/2023 at 1:29 PM, Liv_94 said:

Wow that’s more detailed than what they said to me. I don’t live in NC either my company is based in NC as well and this was the letter they sent me

wow yeah that is much shorter...I also had to ask my baratric team for a copy - as I still havent recieved one from BCBSNC. Well I sent over my "compliance" with diet and exercise from the first surgery...hopefully its enough info. I also sent in proof I was proscribed anti acids for months during my pregnancy and doctors notes on how intolerable it was to eat and take meds with my gerd...

we will see if thats enough with the peer to peer review...I'll keep updating on here when I hear something.

you give me hope...thank you for sharing!

[Liv_94 4]

On 10/24/2023 at 2:38 AM, Ambular said:

wow yeah that is much shorter...I also had to ask my baratric team for a copy - as I still havent recieved one from BCBSNC. Well I sent over my "compliance" with diet and exercise from the first surgery...hopefully its enough info. I also sent in proof I was proscribed anti acids for months during my pregnancy and doctors notes on how intolerable it was to eat and take meds with my gerd...

we will see if thats enough with the peer to peer review...I'll keep updating on here when I hear something.

you give me hope...thank you for sharing!

I really hope they review quickly and reverse that decision for you!

[Ambular 4]

On 10/25/2023 at 4:55 PM, Liv_94 said:

I really hope they review quickly and reverse that decision for you!

Thank you! my Peer 2 Peer is Nov 2nd. So we will know more then ❤️

[Ambular 4]

On 10/25/2023 at 4:55 PM, Liv_94 said:

I really hope they review quickly and reverse that decision for you!

Surgery date is scheudled for the end of this month

[Liv_94 4]

On 11/7/2023 at 8:25 PM, Ambular said:

Surgery date is scheudled for the end of this month

Congratulations!!! Glad they decided in your favor. It’ll all be worth it!

[Ambular 4]

On 11/18/2023 at 4:51 PM, Liv_94 said:

Congratulations!!! Glad they decided in your favor. It’ll all be worth it!

So far its so worth it ❤️