Anyone have revision approved by BCBS?
I have BCBS of Florida. I am trying to have a revision to have my pouch size reduced and stoma tightened (please no e-mails about DS...I have made my own personal decisional and it's final). I was just denied by BCBS for my revision which was scheduled next week. My policy covers the treatment of MO including surgery. I had 6 months supervised diet with my PCP. I have actually been seeing my surgeon who will do the revision for over 18 months. I have a hernia that was going to be repaired at the same time. I still weigh 300lbs, down from 502, 462 pre-op 3 years ago. But stop losing after 1 year. My pouch is way to big and my stoma is too big. BCBS said not medically neccesary. Since my original surgery I have had a DVT, nonWLS related and 2 mini-strokes...only risk factors now for future strokes is my weight and I am only 28. I have never weighed less than 300, followed protocol...actually was stalled at 330-340 for 2 years and recently took off the extra in preparation for this surgery...felt like I was starving myself. Have NEVER had the quickly full feeling. I called BCBS to asked what their requirements for a revision were...not like my surgeons office hadn't gotten them before we proceeded and we thought we had met them....but anyway no one could give them to me...said case by case. But what they told my surgeons' office was the reason for the denial sounded like they were denying a reversal...said unless I had malnurishment or rapid weightloss a second bypass wasn't deemed neccessary...something just isn't right. Once my surgeon gets the letter of denial they will do the peer-to-peer review.
Can I shed some light. I have Anthem BCBS and I just had my revision in Jan 06. My surgeon fought for 18 months with my insurance. They would say it wasn't medically necassary and blah blah. What it came down to was my surgeon went in front of the insurance medical board and told them if they did not surgically fix this problem, I could potentially wind up with other greater medical problems or die. My first surgery was in 99 I had the stapling with the ring. I lost my weight and kept it of for about 4 yrs and started gaining and gained about 70 lbs but I had a vomitting problem. I vomitted up everthing I put in. So my body stayed in starvation mode. My esophagus lining was also so thin it was scary. So, I had the revision ru and it was a fight with the insurance. I also have had some complications with this surgery. Not to bad but more than I was really prepared for. I guess I assumed it would be like before and it was nothing like before. I just want you to know there is hope with BCBS. I know for a fact that they do not cover bariatric surgery initially but, you and your surgeon need to present it in a way that medically this is the only treatment that will fix the initial problem that could lead to other problems.
I also wrote a letter that they submitted as well. Best of luck, it will work out.