Understanding Anthem Blue Cross Revision

I have Anthem Blue Cross and am in need of revision or conversion surgery. My plan benefit coverage states the criteria for weight loss surgery: bmi, 12 months medically supervised diet program, etc. However, the plan booklet does not give criteria for weight loss revision. It does not mention revision at all. I had the sleeve done in 2010 and 2 months later I was having chemo for breast cancer. With the excessive vomiting that resulted, my sleeve has stretched (surgeon described it as an orange sitting on top of a banana). I have acid reflux, sleep apnea, joint pain, and have regained 70lbs. The surgeon also stated that the sleeve dilation puts me at risk of ulcers.

Anyway, Blue Cross's "Medical Policy" for bariatric surgery does list the criteria for revision (one is pouch dilation due to excessive vomiting) and my revision would qualify as medically necessary. My surgeon has included my situation in his progress notes.

Since my plan does not specifically mention criteria for revision but the insurance's medical policy does, how will Blue Cross base it's decision? I'm gearing up for an appeal via State of CA. I'm so stressed...thanks.

I think you would have to go by whAt your plan says!as your plan is the coverage your employer has bought for employees.

just because the broader Blue Cross plans says it covers it,doesn't mean your employer has bought the coverage for its employees.

i also have BCBS and Wls is an exclusion on our plan because the employer didn't buy the coverage.

gl