Is He FOR REAL?!?!?!?!

Hi Everybody!

It's days like today that I'm so glad this forum exists! The wealth of information is just AWESOME! :-D

Anyway, I had my follow-up consultation with my Dr on Thursday. My initial consultation was last week and he was giving me some time to think about it to see if WLS was really what I wanted to do..DUH!!! HECK YEAH!! I had a VBG back i***** and have since gained back all my weight plus 10 and I'm looking into being switched (pardon the pun) to a DS. He ordered an Endoscopy for next week and was going over the whole procedure, answering any questions I might have, blah...blah...blah.. and then he said after the Endoscopy he was going to submit the letter to the insurance company the following week!!

:-oWHAT!???!!! REALLY??? FOR REAL??? I was not expecting him to say that!!!

I have AETNA as my policy and even though I know it does cover revisions, I was thinking they will probably require me to jump through all the hoops as if I had never had surgery!! Their policy states that you either have to do a 6 month supervised diet -OR- a 3 month multidisciplinary preparatory regime of meeting with a dietician, psychiatrist, and you PCP. I'm only in month 2 of my 3 month regime. I told my doctor this and he said that because of my previous history, he didn't think their other rules applied.

This is what AETNA's policy officially states with regard to revision:

Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction or stricture.

III. Repeat Bariatric Surgery:

Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:

1. Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure;

or

2. Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure.

Can somebody help me with this one??? At the earliest, I was thinking I may be able to have my WLS in February, but the way he was talking, I might be able to get scheduled next month, which would be great!!! But a small part of me is expecting them to reject the 3 month regime (even though their policy says you have a choice) and force me to do a 6 month diet. What do you guys think? I don't want to get my hopes up! -Angie

when I had my revision back in March I had Aetna.  I only did the 3 month multidisciplinary preparatory regime plus they made me keep an exercise log (I exercised anyway so that was not a problem) and I was approved the on the 1st try. To be honest Aetna was easy to work with.  Good luck hope you can have your surgery sooner rather then later. MJ

I had BC/BS but I didn't have to do all that other stuff;  They a;pproved me in a couple of days and my surery was scheduled in a couple of weeks.  I barely had time to freak out.  It was great.  Much easier than all the hoops you have to jump through the first time around.  Hopefully, everything will go as easily for you as it went for me.  Goodluck.

I am attempting to get my RNY revised.  My surgeon has suggested an adjustible lap band procedure but Anthem BC/BS has denied it.  I just filed my first appeal so I am hopeful it will ultimately be approved.   Did anyone here have a lap band over RNY?