Denied by insurance for RNY to DS revision

I have been going to appts and working with the U of MN Weightloss Surgery staff (Dr. Buchwald) since August 2011 to have a revision from RNY to DS. They had a surgury date of 12/13/11 scheduled for me and insurance prior authorization was submitted last week. We heard back today that I was denied.

They denied me because they say that weight gain and stoma dialation does not make surgery medically necessary. They also said that the fact that I originally lost weight after the RNY (lost 125 lbs) then gained back (gained 105 back) indicates that I didn't make the necessary behavioral changes. Therefore, they would require counseling then re-evaluation. I have my psych eval, the psychologist recommended the surgery, so they did not take the psychologists opinion into consideration. :(

I am going to look into an appeal, but also plan to look into self pay. I am going to look into Dr. K in CA and Dr. M in Brazil. QUESTION: For those who have had surgery, is it worth draining savings and/or taking out credit for? Has anyone done this and regretted it?

Thanks,
Tina

exhaust all avenues before self paying. appeals, selecting another insurer during open enrollment period. and consider why you failed with the rny, its not the best, but the ds is not fail proof either and a revision is not cheap, and your finances maybe a lifetime decision. 

I agree with Walter. Make really darn sure your insurance wont pay for it first. i had a back up plan if my insurance didnt cover it. I was luck y and they did but i was prepared to fight if it was needed. My backup plan was a last ditch effort.

Im a lapband revision so i understand having a previous WLS that didnt work. But please if you dont already, continue seeing the Psych. A revision is a lot to take on and you will need all the support you can get:)

Good luck hun! Many vets have good info on how to go about an appeal so ask around and make sure to have all your T crossed and I dotted:)

HI,

Diana Cox may be able to help you with an appeal.  PM her and ask.  There are studies that show that RNY has a HIGH % of regain, not the patients fault!!

The 2 doctors that you are considering are excellent surgeons but Dr. Marchesini is not doing very many RNY to DS revisions on foreign patients.  I love him and would marry him (if he didn't already have a wife) but I wouldn't use him for a revision from RNY at this time.

Dr, K is also an excellent surgeon and he is one of the top revisions surgeons available. Dr Rabkin in SF is also a top revision surgeon.

I was a revision for a previous WLS (not RNY) and my insurance would have covered RNY 100%, right down the street from my house.  I robbed my retirement, and took out some credit to fly to Brazil and get my DS.  Yes, it is worth it!!!

Michele

Contact Dr K's office and see if he can help. He can tell you (actually your insurance company) in great detail why the rny does not work. A peer-to-peer may get you that approval. How can the insurance company even prove you were non-compliant? They can't and with the help of an expert like Dr. K explaining it to them, they will have no basis for their decision. This is a typical insurance ploy to see if you will just go away.

Here is Dr. K's contact info:

Ara Keshishian, MD, FASMBS, FACS
Phone: 818-812-7222

Appeal! Get Dr. Buchwald to help you. If you have documentation of a dilated stoma, that is (IMHO) a mechanical failure of your RNY, and how your insurer could accuse you of causing your stoma to dilate is beyond me. With a dilated stoma, the small size of your pouch is useless, because food just falls through the large stoma directly into the small intestines. Therefore, you have no restriction, and since RNY works almost entirely via restriction, your RNY is no longer functional.
      You didn't fail. The surgery is not working as designed because of the enlarged stoma and IT has failed, not you. But of course your insurer doesn't want to pay for an expensive revision, and is using your weight regain as an excuse, when in fact the weight regain was almost inevitable once the stoma dilated - again, NOT YOUR FAULT!
     Keep in mind that when you exhaust your internal appeals, you should also have external appeals available, which means an outside reviewer without a financial stake in the game. Don't give up!

Larra

 I agree with Larra. That was the very reason I was able to have my revision surgery with Dr. K. dilated stoma.

Explore all your options and appeal.....as the others have said.

To answer your question, I was self pay and it was worth every penny!!! BTW: I highly recommend Dr. Keshishian, but I'm a little biased.

Thanks for all of the support and words of encouragement.

I spoke with the nurse that worked on my prior auth. She said that my behaviors caused the dilated stoma. I pointed out that their policy lists dilated stoma in the reasons for revision. She agreed that it was listed in the policy. She then told me the medical advisor wants a paper trail that shows I have seen a counselor and understand the behaviors necessary to be successful with the DS. She said that 8-10 visits should suffice.

I already have my first counseling appt set up. I will go for 3 months then appeal.

I am going to keep fighting!

What a bunch of crap - your behaviors did NOT cause your stoma to dilate.

Behaviors necessary to be successful with the DS:

1) Eat your protein - make sure some of it is bacon, because you can
2) Take your supplements religiously
3) Get your labs done religiously
4) Watch your carbs, but enjoy your mayo and butter
5) Enjoy your food

Is there more?  Does it take 10 appointments with a counselor to commit this to memory??

This kind of bull**** just ****** me off.  I'd do two appointments and start the appeal.