Article for why BMI is not a requirement in revision?

Hi all,

I'm in a 14th month fight with Federal BCBS over revising my lap band to a VSG. They finally agreed to take out the lap band and that was done in October, but now they're still denying the revision part. At first it was because it wasn't medically necessary, then it was because my BMI wasn't over 35 (which is now is), now it's because my BMI isn't 40. Every bariatric surgeon I spoke with is appalled that you'd have to gain weight to get a revision. My surgeon even wrote a letter stating that a BMI requirement is not the standard of care in a revision.

What would be super helpful is to find some sort of article or policy about the standard of care for revisions that mentions the BMI. Anyone know of anything like that? I'm googling to death but haven't found anything yet. I'm trying to get this resolved with the OPM in DC this week.

Thanks!
Britt

Your surgeon is correct, it is the Standard of Care in the US and MX to actually revise from band to sleeve in the same surgery regardless of BMI assuming there is no slip or erosion.

They do not have to pay it unless your BMI is 35 and you have the required co morbidities or you have a BMI of 40. They have the legal right to make you follow the agreed upon contract. :0(

I know it makes no sense. This is why I went to Mexico and just self paid for a revision.

Well it turns out I found out that Regence does have a revision policy - BMI is not a requirement, if the first surgery fails, the second surgery is covered. I found similary policies for Medicare and 7 other insurance companies.

I also wrote a letter to the American Society of Metabolic and Bariatric Surgeons (ASMBS). They were kind enough to reply and it turns out they published a position papter that also clarifies the standard of care for revision is only that a prior surgery failed.

That was enough for me to want to resume the fight. I put together an other letter, faxed and overnighted it, and now I'm waiting for my attorney to have a conference call so I can find out whether it's enough for them to reopen my case.

What's most difficult is that I scheduled surger with Dr. Aceves last week when I thought my appeal was final. Now I'm really anxious to get an answer one way or the other. If my appeal is really over I want to get on the plan on Friday and get on with my life!

I've posted my new letter in case it's useful for anyone else.

Thanks!
Britt

http://vsgappeal.blogspot.com/2010/05/final-letter-why-revis ion-doesnt.html