Anyone here had a revision using the PHP/Cofinity Insurance?

If so I have a question for you.  I'm currently in the process of getting my lap band switch to an RNY because of Acid Reflux and hernia issues, however I rec'd a call today from one of the ladies who is reviewing my case with a few questions and after I got off the phone the more I thought about how strange the phone call was....and I was wondering if anyone else was asked strange questions like mine because something just didn't add up....don't get me wrong i beleived it was the insurance company because when i called my pre-op coordinator she called me back and confirmed the lady called and left her a voicemail for some quesitons:

1. The PHP rep wanted to know who paid for the 1st surgery back in 2006, when I told her I was under my parent's insurance company MEESA they were the ones who approved the surgery ---what i'd like to know is why does PHP care if a diff ins company paid for a surgery? Is it even any of their business/concern?

2. She ask me why I never called the Sparrow Weight Management Program (I called the female baratric team - who denied me as a patient, I had a jerk in Owosso - who I left, I called the drs at sparrow who perfomed the lap band surgery and never rec'd a call back), had I thought about finding  lap band dr in the EL area (I go to Dr. Kemmeter in GR), how did I become a patient of Dr. Kemmeter (through a refferal here and took my chances), have I thought about going to an OBGYN up here (my obgyn gave me a referral letter the first time around because I have PCOS and she was the one helping me w/the pcos)

3. They also wanted to know what care I rec'd w/ my first surgery - i.e. internist appt, saw the psychologist, saw my drs nutritionist.  They were a little surprised that I wasn't on a "diet" however, i had my parent's insurance I was actively on weigh****chers and I had been on it for 4 years and provided documentation, plus i had the qualifications w/the insurance company....

so i dunno what to think - i've never had to have anything approved before where the insurance company called and asked me odd questions (when i had my lap band surgery the drs office took care of everything) so I was just curious :)

thanks!

Haven't dealt with your particular insurance, but like any insurance company, they are looking for ANY & ALL reasons to deny you the revision (and not foot the bill).

You don't mention mechanical failures of the band, or where you are weight-wise, so with that in mind, here is my general input:

1.  Your insurance (past & present) may have a  *1 WLS per life maximum*  (which is not uncommon and is happening more & more).  If your previous policy did (they policy the paid for your first WLS) then you could be SOL.

2.  They want you to work with someone they have under contract (in network means = less money for them to pay out).  You are not bound to this, especially if you have special cir****tances (medical reasons) for needing a  *specialist*.  If you just don't  *like* who they have in network, you could have an issue.  But, revisions are tricky, and should NOT be trusted to someone who is not a skilled revision surgeon (Kemmeter is).

3.  You may not qualify for WLS under your current policy, by their standards.


Here is a bit of a rant (and not directed at you -- just frustration in general) -- I get so erked when I see people post that  *if my VSG doesn't give me the results I want, then I will get a revision*.  Fill in the surgery, it isn't just VSGers.

We are all hopeful going into our WLS, convinced that what we are getting is right for us (or is it just what the surgeon sold us on?) and we are not going to be the one to fail.  When this doesn't happen, we really start to educate ourselves and look for options.

Now, what you are up against:

** Will your insurance even cover a second WLS.  Most won't, unless their is a documented failed mechanical issue, which requires additional surgery, and has very little to do with you needing to lose more weight.  And some won't even cover the revision, but only getting the band dug out of your stomach (or any number of things).

** If they will cover it, you may still be obese, but not qualify.  If you end up with some weight loss, but still have a BMI between 35-40, you will likely still need to have co-morbs to qualify.  If not, you will need to be over a 40 BMI to qualify.

** Still another hoop??  Yep, if your insurance requires a pre-op diet, you will need to go through it again.  3 months, 6 months, whatever they require.  And, hopefully you don't fall below the magical BMI number.

** And the big gun hoop -- a LOT of them are requiring 5 years of documented weight records!!  You need to prove that your  *tool*  didnt' work for 5 whole years before they will even consider allowing you to begin the WLS process again.

Sorry, I just see this all the time on the DS Forum, and my heart just breaks for people that gave it their all and their surgical choice failed *them*. 

I would strongly suggest getting the complete copy of your benefits (usually you aren't given the details with all the fine print -- if your employer can't provide it to you, you can usually download it from your insurance website -or- request that they send this to you -- immediately!!  I would then suggest posting these same questions on the Revisions Forum, as there are a lot of people there that have had to battle insurance, sometimes for a really long time, and they will be your best source for making sure you handle your insurance company properly  (ie -- don't give them any reason to deny you!).

Good luck.  I know it sucks dealing with insurance companies.  I hope you can get through all of this and get onto improving your health!

thanks.  i'm going to call my HR department to see if any of their policies have changed, we are staying w/the same insurance company for another year, however I'm curious to know if anything has changed for the new term...I also have my obgyn appt and endo appt coming up and they've both been very supportive of everything i've done, gone thru etc I'm thinking about asking them to write "reference letters" in case I'm denied or something, so I'll have some back up. 

My mom's insurance was quite wonderful I had it back in 2006.  They only needed 12 months of diet (i.e. weigh****chers, medical weight loss etc), I needed the 3 co-morbs (I had PCOS, a BMI of 36-37 and SAD) and something else and within two weeks it was approved...*sigh* to be 22 again...