Insurance Guidelines For Revision Surgery

I was researching on the WEB, and came acroos several insurance companies with their Revision/Reoperation guidelines posted on their website. If you notice, your BMI is not considered a factor in the guidelines. The BMI condition was only a factor for the INITIAL surgery. I thought this was very interesting. I was under the impression based on feedback from the Doctors, in order for insurance to approve and to qualify for a Revision your BMI must be greater than 40 or 35 with co-morbidities.  Right now, I found information for BCBS of NC, CIGNA, and AETNA. I called my own insurance company , EMPIRE BC/BS and the rep said they don't post the coverage on their website, but as long as its medically necessary and the Dr fills out a predetermination form. If I find additional information on other insurance on other insurance companies I will post to this string.  Good Luck everyone!  We wake up each day and wonder do I really have a 2nd Chance at this?  And guess what, WE DO! and we are not FAILURES! BCBS of NC: C. Reoperation and Surgical Revision-The following may be considered medically necessary for patients whose initial surgery met medical necessity criteria:

1. Surgical reversal (i.e., takedown) when the patient develops complications from the original surgery

such as stricture (narrowing) or obstruction.

2. The following are examples of conditions and/or diagnoses for which revisions to the primary surgical procedure for morbid obesity may be covered:

a. Weight loss of 20% or more below the ideal body weight;

b. Esophagitis (e.g., esophageal reflux);

c. Hemorrhage or hematoma complicating a procedure;

d. Vomiting (bilious) following gastrointestinal surgery;

e. Gastrointestinal complications, (i.e., complications of intestinal (internal) anastomosis and

bypass);

f. Stomal dilation, documented by endoscopy; g. Pouch dilation documented by upper gastrointestinal examination or endoscopy, producing weight

gain of 20% or more provided that the primary procedure was successful in inducing weight loss

prior to the pouch dilation, and the patient has been compliant with a prescribed nutrition and

exercise program following the procedure (compliance with diet and exercise must be documented

via a detailed evaluation by a mental health provider and/or nutritionist);

h. Stomal stenosis after vertical banding, documented by endoscopy, producing vomiting or weight

loss of 20% or more;

i. Other and unspecified post surgical nonabsorption (i.e., hypoglycemia and malnutrition following

gastrointestinal surgery);

j. Other post-operative functional disorders (i.e., diarrhea following gastrointestinal surgery);

k. Severe dumping syndrome;

l. Post-gastric surgery syndromes (i.e., post-gastrectomy syndrome, post-vagotomy syndrome);

m. Disruption of operative wound;

n. Staple line failure, documented by upper gastrointestinal examination;

o. Disrupted staple line provided there has been prior weight loss. CIGNA Reoperation and Repeat Bariatric Surgery:

CIGNA HealthCare covers surgical reversal (i.e., takedown) of bariatric surgery as medically necessary when the CIGNA HealthCare covers revision of a previous bariatric surgical procedure or conversion to another medically necessary procedure due to inadequate weight loss as medically necessary when ALL of the following are met: CIGNA

• Coverage for bariatric surgery is available under the participant's current health benefit plan.

• There is evidence of full compliance with the previously prescribed postoperative dietary and exercise program.

• Due to a technical failure of the original bariatric surgical procedure (e.g., pouch dilatation) documented on either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD), the patient has failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body weight or failure to achieve body weight to within 30% of ideal body weight at least two years following the original surgery.

• The requested procedure is a regularly covered bariatric surgery (see above for specific procedures).

NOTE: Inadequate weight loss due to individual noncompliance with postoperative

nutrition and exercise recommendations is not a medically necessary indication

AETNA Repeat Bariatric Surgery:

AETNA:

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

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.

Hi- Which Aetna plan was it that you were reading about?  I have Aetna HMO and it flat out says it doesn't cover bariatric surgery.  I've seen others who had the HMO who had the revision surgery, so there must be a way.  I was just wondering which Aetna plan that one you mentioned was. Thanks-

Hi I only looked at the Aetna's website, not specific to any Aetna healthplan. http://www.aetna.com/cpb/medical/data/100_199/0157.html

O.K. Thanks- I'll check it out.

Aetna does cover bariatric surgery, however, Aetna has many group benefit plans (ie, insurance benefits from work). The various types of plan (HMO, POS, PPO, Indemnity, etc) is specific and some are customized to the group benefit plan.  So, while your insurance benefits through Aetna specifically exclude coverage, that's not likely to change.  The clinical policy bulletin does clarify that though in the opening paragraph of the clinical policy bulletin... I have Aetna Open Choice II POS through my employer and it is absolutely covered per the company, and per Aetna...just a matter of getting all my ducks in a row... Luv  Sharon