Revision from Band to VSG-UHC denial- need help with appeal

Here is my story-

I had lapband surgery in Jan 08. I had 3 or 4 fills and originally lost approx. 55 lbs. in the first 4 months. I maintained that loss for another 6 months or so, but started having occasional problems with pain radiating to my right ear, reflux, occasional regurgitation. I started drinking water with my meals in order to get food to go down easily and then eventually started to gain weight back because I could "drink" down pretty much anything. Over the last year I have gained back about 30 of the 55 lbs that I had lost.  I went to a new doctor (my original band doctor leaves much to be desired regarding follow-up care) in February and he did a very extensive upper GI and they found that my band has slipped-causing the reflux, discomfort, etc.
After researching VSG EXTENSIVELY over the last month and a half I decided that I wanted to revise my band to a VSG. I spoke with my new doctor and he agreed with my decision. My BMI is 48.5 right now and my doctor will not even do initial lapbands on patients with a BMI that high because the medical research (which he showed me) does not support it. 
I have United Healthcare (they also covered my lapband), and my policy says that it will cover only one bariatric procedure per lifetime unless there are complications.  So I patiently waited for my approval over the last few weeks, then 3 days ago I get a call from my drs. office saying that the insurance company had DENIED my revision to a VSG-but get this- they WILL pay to have the band removed or REPLACE the band with a new one??????? That is absolutely crazy in my mind! They acknowledge that my band has slipped and needs to come out but only will pay to have it replaced with another band so that it can fail again in another x number of months! 
I had the insurance company do a peer to peer review with my doctor yesterday and they still are going to deny it.  
I am obviously going to appeal the decision and my husband has a call in to his HR insurance coordinator to complain. 
I'm asking for any help that anyone might have to offer-ideas, information, letters, research, etc.
I am so totally discouraged right now and depressed-I was hoping to have my revision in the next few weeks and now who knows how long it will take? 

Thank you so much for any help that you can offer.

Were those the only options they gave?  By reading the medical policy it looked they would possibly approve a revision from a band to a combined restriction/malabsortion procedure, but not from a band to another restrictive only procedure.

 Those were the only options that they gave me via phone call from the insurance company.  I have not recvd the actual denial letter in the mail yet (should get it in the next day or two with the instructions for appeal) but the representative told me those were the only options.
I'm anxious to see if denial letter explains WHY they will only replace  or take out the band.
But if that's the case only restrictive to a combined restrictive/malabsorption procedure then why on earth would they want to replace it with another band-totally baffles me????

They have the right to do this.

They are covering one WLS per lifetime.  They will fix your choice of a band by repositioning or replacing it but a VST is a 2nd WLS.  Whole different ball game.

This is why I don't like bands, the odds of them not working are great.  I would never suggest someone get a band if they have one shot in a lifetime at this.

I have a hunch that many ins co's are tired of paying for repeated WLS.  People get bands thinking that they know the success is not great but if it doesn't work they will revise to something that does work.  Not saying you did this, just that many do.  I see it on the boards all the time.  Ins co's want you to get the right surgery the first time and they don't want to pay for repeated surgeries and I can't blame them.

More and more ins co's are going this route and you know, it's working.  People are thinking long and hard and not opting for banding. :o/

 I can kinda see your point MidwesternGirl, with the one WLS per lifetime.  But my doctor, who is on United list of Bariatric centers of excellence, won't even put another band in (even if I wanted one-which I DO NOT), because he won't do lapbands on anyone with a BMI over I think 40-the research says they are effective for 40% of your weight loss only 40%of the time.  It baffles me that they would agree to replace it with something that they will most likely then have to pay to take out again in a year or so.

I makes me soo extremely frustrated-I thought that I had researched the lapband so well before my surgery 2 years ago and truly thought that there was no way that I would not be successful with it. The number of people that I saw having issues or problems online since then has just multiplied 10 fold or more. So many people with slippages, no restriction, regaining!
I plan to appeal the denial-Have you heard of anyone having success appealing a denial under this type of cir****tances?  Do you have any suggestions on research to present or points to consider while putting together the appeal?

Thank you so much for your response and suggestions -you seem to be very knowledgeable regarding insurance info. I would just think that if the VSG has a greater success rate (comparable to gastric bypass at 4-5 years out) and the band has such a high rate of failure, they would approve the VSG with the hope that they will not have to pay for another removal/replacement surgery in the near future.

As far as insurance companies not wanted to pay for repeated WLS surgery, obesity is a disease that they should acknowledge and have to treat. They have to pay for blood pressure and diabetes meds, cancer treatments and sometimes multiple surgeries, extended and multiple ICU stays for people with heart disease, and the list goes on and on.

I understand your point, problem is... your insurance company does not care.

Think of it this way, they will pay for one WLS type in a lifetime and they will pay to take care of that WLS type for a lifetime or as long as you have WLS benefits on your policy.

I really really think the reason for this is that people are getting less invasive surgeries knowing full well if it doesn't work they'll just revise to something with better stats and they are trying to prevent paying for additional surgeries.  Look at the trends, people with insurance are getting lap bands, self pay folks are getting sleeves.  People who have bands/bypass only on their policy are not even appealing to get sleeves or DS.  Even though stats are not showing similar results for bands/bypass vs. the more invasive procedures such as sleeves/DS people still want least invasive thinking if it doesn't work they'll revise later.  If you were the ins co, wouldn't you find a way to put an end to it?  Check out the revision boards, it's FULL of bands and bypass wanting revisions to sleeves and DS.  Revisions are very expensive, especially bypass to DS.

Bands haven't had great stats from the beginning.  On Allergan's website they have had the same information posted for many years.  I believe the figure is 88% of people have issues.  To be honest the people having problems were HUGE in number when you had your band placed.  Tons of people posting warnings about the band on every single WLS board at that time.  But people get really focused before surgery and they really do ignore the bad because they want least invasive.

Heck, I can show you an example of a person that is self pay and she's going to the WORST place in Mexico knowing full well someone at that clinic is passing himself off as a doctor when he's not (he doesn't so surgery, he owns the clinic), we have proven he's not a doctor, we have proven the clinic is not licensed, we have proven they have horrific stats for infections, leaks, complications, and sheer danger in going there.  We have proven the surgeon is not board certified, we have proven the doctor isn't qualified to be ASMBS or FACS and guess what?  She thinks we are all trying to get her to go to our own surgeons (many different doctor's patients are posting and not once has any of us suggested any other specific surgeon) but this place is cheap so she's going there.  She's ignoring the bad because she's obese and desperate and she'll take the risk because a sleeve is only $5500.  We have posted proof and links to Mexican gov't websites so she doesn't have to believe us, previous patients of this doctor have posted warning her, previous coordinators that quit because of patient safety issues have told her she's making a mistake, she doesn't care.  She is picking and choosing what she wants to believe.  People do it ALL the time before surgery, they are scared, broke, whatever and they will settle for less by ignoring the bad.  I see people with bands doing it all the time, read the band boards and you'll see what i mean.

Here, I found the link, Allergan has had this posted on their website for at least 4 years now:

www.lapband.com/en/learn_about_lapband/safety_information//

I'm not really sure a sleeve would work for you anyway.  You didn't have severe problems after 4 months post op but you didn't lose anyway for six additional months.  You said the problems were occasional with barfing once in awhile.  Everyone with a band barfs once in awhile, that's to be expected.  I'm not picking on you, i just want you to think about this.  Sleeves are restrictive only just like bands.  If you are going to try and appeal or end up self pay, maybe malabsorption might be a better battle to fight for?

I've never seen anyone win an appeal after a peer to peer review failed.  Sorry, I'm not trying to be negative, just realistic.

 I went through my husband's company's benefits booklet today and read through the very detailed list of benefits and exclusions.  There is no statement in the bariatric section that the policy covers only one surgery unless complications arise. I was trying to find the exact wording of that specific benefit.  It's not even mentioned, so I'm confused. Wouldn't that have to be included in the benefits booklet so that people can make an informed decision when choosing a bariatric procedure?

I agree that most people will opt for the least invasive WLS surgery option available for them in most cases. But doesn't that make sense? They don't necessarily think, Oh I can always have another procedure later.  After researching the band they are opting for a procedure that is less invasive, "debatably" reversible, and according to the Allergen website even though 88% of the people have some type of complications (regurg and reflux included) only 25%  of the 299 patients in the study had to have their bands removed. I am not advocating for the band-I want mine OUT, and am starting to lean toward the idea that they should be taken off the market completely.

I tried to think back to my mindset at the time that I decided to get my band surgery.  It was such a HUGE decision to actually consider surgery in the first place.  I knew that I was at the point that I needed help with this battle I have been fighting my entire life, but I was truly scared to death of having to opt for surgery.  I researched the band, and was on lapbandtalk and local band group sites for endless number of hours.  I read stories of people that had problems with getting to their sweet spot, occasional PBs, and then people that had bigger problems with slips and dilations.  But I also read through pages and pages of success stories and picture updates that motivated me and helped me believe that I could be one of those success stories too. Isn't that what we all want-to believe that we can do it? Life is a lesson, we live and learn. In hindsight, I wish that I could have known/realized then what I do now. 

As far as more self pay people opting for sleeves-there are many people out there who's insurance companies don't cover VSG that don't even know that appealing is an option for them or wouldn't know where to start with an appeal. Their surgeon's office says that their insurance will cover a band or bypass and they pick between the two. I personally know of someone right now considering WLS that will probably end up having bypass even though she wants a sleeve, because her insurance will not cover sleeves and she has no resources to finance the surgery herself.  My cousin and I have tried to explain that she has the option to appeal, but many many people don't have the knowledge, resources, support to go through all of that.

I have thought about the sleeve and asked many questions on other WLS boards.  The band worked for me in the first few months when I had the proper restriction and could eat the small amount I was supposed to, even with the expected occasional pbs from forgetting and taking too big of a bite or eating too fast.  The problem arose when I started the battle of too tight, dilated pouch, pb, drinking anything/everything down, etc.. I researched DS and with 12 hour shifts as a NICU nurse I can't take the risk of possibly having the bowel issues that many people experience even if its temporary.  I truly am not opposed to the malabsorption of the bypass, I just wish they could do it with a "sleeved" stomach (less ghrelin, less chance for stretching of the new stomach).

Anyway, I don't think that your picking on me (I'm pretty thick-skinned) and I truly appreciate your take on everything. You helped me understand "why" the insurance company doesn't want to pay for the surgery and are helping me think of ways to battle them over it. We are paying insurance premiums that include bariatric surgery, so I (as well as my husband) intend to do everything that I can to try to make them pay for the revision. 

We'll see...

~~I went through my husband's company's benefits booklet today and read through the very detailed list of benefits and exclusions.  There is no statement in the bariatric section that the policy covers only one surgery unless complications arise. I was trying to find the exact wording of that specific benefit.~~

You don't look for the exact wording in a benefits booklet, you look at the actual policy for that.  The benefits booklet is just that, a booklet.  An overview of the policy.  You'll get details from the policy.  The booklet is not legally binding, the policy is.  Keep in mind, you need an updated copy of your policy, not necessarily the one you originally started out with.  If the employer opted for changes, or if the ins co changed things, you'll need an updated copy of the actual policy.

~~It's not even mentioned, so I'm confused. Wouldn't that have to be included in the benefits booklet so that people can make an informed decision when choosing a bariatric procedure?~~

No, not at all.  That is what the policy is for.

~~I agree that most people will opt for the least invasive WLS surgery option available for them in most cases. But doesn't that make sense? They don't necessarily think, Oh I can always have another procedure later.~~

We'd have to disagree on that.  I see people all the time on the band boards writing... well, if it doesn't work then I'll resort to bypass.  Or... my husband refuses to let me get "name your surgery type" until I try the band first.

This sends shivers up my spine because they don't realize that revision surgeries hold 3x the risk as working on a virgin stomach.  They didn't have much risk as a newbie but as a revision they are loaded with risk.  The logic here is where? ;o)

Heck, *I* did that!  I didn't want bypass, I figured I'd try the band and if that failed, oh well.  I'd either be fat or wait for something else non-malabsorptive to come along.  At that time there were no long term stats on the sleeve and it was assumed the sleeve would no do well.  That assumption was wrong. ;o)  But you know, I was using my own money at the time so I could do as I wanted.

~~After researching the band they are opting for a procedure that is less invasive, "debatably" reversible, and according to the Allergen website even though 88% of the people have some type of complications (regurg and reflux included) only 25%  of the 299 patients in the study had to have their bands removed.~~

ONLY??  You don't think 25% is statistically significant?  That doesn't even include the re-ops for mechanical failures.

~~I am not advocating for the band-I want mine OUT, and am starting to lean toward the idea that they should be taken off the market completely.~~

Welcome to my world.  ;o)

~~I read stories of people that had problems with getting to their sweet spot, occasional PBs, and then people that had bigger problems with slips and dilations.  But I also read through pages and pages of success stories and picture updates that motivated me and helped me believe that I could be one of those success stories too. Isn't that what we all want-to believe that we can do it?~~

Did you look to see WHO was posting that information?  Usually it goes like this...

Post op folks from 0-6 months are in love with their surgery type and in love with their surgeon, doesn't matter what surgery type.

Those from 6-12 months are figuring out that they are doing the work, not their surgeon but they still love their surgery type.

12-18 months the band problems are kicking in but the scale is moving, they'll deal with the issues.

18-24 months and they are sick of the band and considering revision.

24+ they are getting revisions.

I guess one really needs to evaluate if it is wise to listen to a person 3 weeks post op and how much they love the very surgery type they haven't had time to live with yet.  I think THAT is the #1 problem with people researching today.  They are so eager and desperate, quite frankly, to lose weight they don't research WLS in the same way they would a car.

~~Life is a lesson, we live and learn. In hindsight, I wish that I could have known/realized then what I do now.~~

You know what the problem is with WLS?  WLS is like a pair of really cool shoes.  You can look at them, think they are beautiful.  They look like the right size, they seem like they will fit, they look really comfortable but you know, you really don't know what kind of blisters you are going to get until you try them on and walk in them for a mile.  We look at the price, we look at the style, we look at all kinds of things but even if the info did exist on just how many people were harmed by those very shoes 6 months down the road, most wouldn't read it anyway.  We want those shoes!

Consider this, we want WLS a whole lot more than those shoes. ;o)

~~As far as more self pay people opting for sleeves-there are many people out there who's insurance companies don't cover VSG that don't even know that appealing is an option for them or wouldn't know where to start with an appeal.~~

I do not see that as an excuse.  Not in the least.  When people get their denial letter the instructions are right there in easy to read letters.  It is required to be there by law.  And this IS elective surgery, there is no excuse for not doing a ton of research on all surgery options available.  Just googling WLS will bring up hundreds of thousands of hits.

~~I truly am not opposed to the malabsorption of the bypass, I just wish they could do it with a "sleeved" stomach (less ghrelin, less chance for stretching of the new stomach).~~

Dilating the pouch isn't my biggest concern with bypass.  My biggest dilation concern is dilating the stoma.  Think about my sleeved stomach, if I dilated it by 100% ... so what?  I can eat another 3 oz?  If eating an extra 3oz of food is going to cause me to regain 132# it's not my ability to eat another 3 oz, it's what I choose to eat.

~~so I (as well as my husband) intend to do everything that I can to try to make them pay for the revision.~~

Good, I hope you win this battle!  Just remember, you are looking at this from a logical point of view.  You are dealing with an insurance company, you can't approach it from that angle.  You have to think like an ins co.  Throw out all logic. :o(

 Then the policy should be readily available instead of the benefits booklet.  It still doesn't make sense to me that they would have all of the WLS requirements listed in the book with extensive info on the "Bariatric Resource Services' program and fail to mention that "oh yeah and your only allowed one procedure except if complications arise, blah, blah, blah.."  I mean really the Benefits booklet is 249 pages, you would think that they weren't skimping in putting it together and could have included that little tidbit!--- But like you said insurance co ≠ logical!

I did not get a chance to see the policy yet. My husband was out of town on business for the day and did not have the opportunity to contact the HR rep to get a copy. I'm am an absolute basket case right now.  I have been staying up late reading boards, looking through medical articles, and looking at things that other people have done to appeal and getting like 2-3 hours sleep at night.  I am totally down-I never even imagined that they would not approve the surgery. I knew United was one of the few ins. companies who actually cover VSG. Obviously the exclusion is not in the benefits book, and the bariatric resource case manager I have been talking with for the past 2 months never mentioned it before! I went from trying to accept going through surgery again, to being ready to go -down to making a list of things to bring to the hospital-I was totally ready and anxious to get it done and start healing and feeling better about losing weight again and then I was blindsided!  I know, I know - like my 15 year old would say, "waa waa call the waaam-bulance" It just stinks!

This sends shivers up my spine because they don't realize that revision surgeries hold 3x the risk as working on a virgin stomach.  They didn't have much risk as a newbie but as a revision they are loaded with risk.  The logic here is where? ;o)

Since EVERYTHING that you read on bands state one of the major benefits is they are reversible-that would lead most people to believe that reversible means reversible.  Even myself, as a registered nurse, did not realize the implications, so how can I expect someone with no medical teaching to understand? They need to start saying  "reversible-but will leave you with full of adhesions, scarring, and etc, etc.."

Yes I think 25% is statistically significant-but better than 88%  

I guess one really needs to evaluate if it is wise to listen to a person 3 weeks post op and how much they love the very surgery type they haven't had time to live with yet.  I think THAT is the #1 problem with people researching today.  

So True, but who is there to TELL them- hey wait- you need to look at your research this way and this is what you need to look for.  You would "think"  looking at people 6-18 months out would give you a good picture of success.  I can remember one person off the top of my head from lapbandtalk.com who didn't reach her goal until she was 2 years out and she did really well with her band throughout that time--Who knows now, I don't frequent that board anymore.

You know what the problem is with WLS?  WLS is like a pair of really cool shoes.  You can look at them, think they are beautiful.  They look like the right size, they seem like they will fit, they look really comfortable but you know, you really don't know what kind of blisters you are going to get until you try them on and walk in them for a mile.  We look at the price, we look at the style, we look at all kinds of things but even if the info did exist on just how many people were harmed by those very shoes 6 months down the road, most wouldn't read it anyway.  We want those shoes!

That is so absolutely true and well put!! And those same pair of shoes might not cause any blisters and be your friend's most comfortable pair.  Each person reacts to each WLS differently.  Can or cannot eat certain things, does or does not vomit, eats a variety of foods vs. staying away from carbs, etc...

I do not see that as an excuse.  Not in the least.  When people get their denial letter the instructions are right there in easy to read letters.  It is required to be there by law.  And this IS elective surgery, there is no excuse for not doing a ton of research on all surgery options available.  Just googling WLS will bring up hundreds of thousands of hits.

Not really an excuse, just an explanation.  The person that I was referring to before, did not even pursue the sleeve in the first place because her dr.'s office told her that it was not covered under her insurance-not covered to her meant okay-not an option.  So no denial with appeal info. (One could argue that they surgeon's staff was not advocating for the patient, but it happens) And despite my cousin and I repeatedly urging this person to research online, I don't believe she has EVER done so.  She is in her late 50s, no computer at home (only at work), and relying on the information from 3 or 4 people at work that have had bypass and been successful. Even though this sounds crazy to you and me, there are a lot of people in this world like that- they don't know the first thing about online research, message boards, etc.  I have run into so many people in different bariatric doctors office that don't have a clue about the information that is out there.  I will tell them about message boards and local yahoo groups and they are like, "well I've been to x number of support groups" ???

Good, I hope you win this battle!  Just remember, you are looking at this from a logical point of view.  You are dealing with an insurance company, you can't approach it from that angle.  You have to think like an ins co.  Throw out all logic. :o(

I hope I win it too-and quickly!  

But just in case, let me pick your brain some more. What happens if you go to Mexico for revision surgery and end up with complications, say a leak, after a week when you are already back home? That is the thing that concerns me the most about going so far away for surgery. Not having the surgeon and staff readily available for you if you should need them, especially with a revision.  I live in Houston, and while there are people who travel a greater distance than that, its not like driving the 15 minutes down the freeway to my surgeon's office. Also, do you know how I would determine if my insurance company covers complications from a surgery either paid for out of pocket here, or out of pocket in Mexico. Just curious.

Thanks again for the informative and thought provoking conversation!

~~ Then the policy should be readily available instead of the benefits booklet.~~

It is.

It is usually on line, it should be available from your HR dept, and is always available from the Ins co.  Now remember, ins co's have a gazillion lawyers.  They cover their collective butts 99% of the time.  As for your benefits booklet it's still an overview and not the actual policy.  The actual policy is harder to read. :o/  I'm pretty sure the lawyers wrote that one.  Also, the policy may have changed since that booklet came out.  Employers cut costs, cut benefits, etc.  It's according to their fiscal year.

~~I am totally down-I never even imagined that they would not approve the surgery.~~

Did you know that most people do not have WLS benefits?  That's why most that need it don't get even one surgery.  My original band would have been covered but like you, I'm not into waiting so I self paid in Mexico.  While I don't regret going to Mexico I do regret not getting a sleeve the first time.

~~Since EVERYTHING that you read on bands state one of the major benefits is they are reversible-that would lead most people to believe that reversible means reversible~~

It *is* reversible!  But that doesn't mean a revision is safer. ;o)  That's why when you do revise you cannot go to just anyone, you will need a revision surgeon.  Removing a band is a piece of cake.  Sometimes they don't even remove the scarring around your stomach.  They cut the band and slide it out from under the adhesions.  If you want a revision they can't do that.

~~Even myself, as a registered nurse, did not realize the implications, so how can I expect someone with no medical teaching to understand? They need to start saying  "reversible-but will leave you with full of adhesions, scarring, and etc, etc.."~~

Pharmaceuticals?  Be honest???  Surely you giggle when you write that? ;o)

~~So True, but who is there to TELL them- hey wait- you need to look at your research this way and this is what you need to look for.  You would "think"  looking at people 6-18 months out would give you a good picture of success.~~

Seen my blog?  It's in a link in my sig.  It's a work in progress, I only started it a couple of weeks ago.  The more I write the more I realize I'm nowhere near done.  But hey, I'm seriously trying.

~~But just in case, let me pick your brain some more. What happens if you go to Mexico for revision surgery and end up with complications, say a leak, after a week when you are already back home?~~

That is what is great about sleeves!  First of all, with a band nobody wants to touch you unless they did your original surgery.  The $$ is in the surgery, the aftercare is a pain for the doc's office.  They want the surgery and accept the aftercare as a necessary evil.

Also, if you do spring a leak you are not depending on bariatric surgeons to fix you.  You can go to any bariatric surgeon, any GI surgeon, or any general surgeon.

Your insurance covers WLS, just not yours. ;o)  They will cover a complication.  If you go to MX you find someone that will cover all your costs for complications at least to the point you are discharged.

~~Thanks again for the informative and thought provoking conversation!~~

HA!  I was thinking when I wrote the last response that I wished we lived closer, I think I like you!  You'd be a cool friend!