What are the requirements for insurance approval for revision?

Hey all, it's my first time posting here. I'm thinking I may need a revision (I'm way ahead of myself, but I'm assuming I have an erosion) and was hoping that if that's the case I can have a revision at the same time my band comes out (IF that turns out to be the case). Have any of you done that? I think I would want the sleeve but I'm no longer morbidly obese and I don't know the requirements. I know surgery to take out the band would be covered as emergency surgery, but how does revision work?

It depends on your insurance company.  A lot of the time it's the same for a first time surgery, unless there is another reason.  Your band erosion could be enough, but I know my cousin in law?  (Husband's cousin) couldn't get a revision because her bmi was normal and they had to take her band out and couldn't do anything else.  she has re-gained some weight, but is doing ok with weigh****chers. good luck!

"but I'm assuming I have an erosion"   How do you know?  I am having trouble with my band, upper GI next week.  What are your symptoms? 

I've been having trouble for a long time. I had surgery in June 07 and got too tight for the first time in September or October and it's been a fight since. Spent a lot of the time too tight and the time in between was too loose because of my numerous unfills. Esophograms showed that my band was placed right. At one point it showed a slight dilation but I had another one since and that went down. Right now my symptoms are complete loss of restriction after having a big fill and measuring to make sure it's all there so I know it's not a leak. The only other explanation there could be is that after my doc took it all out when he was measuring he moved the needle out of my port and put all the saline back into my stomach instead of the band. I feel discomfort in the band area now though so I don't think that's what it is. It feels sore but I have no restriction and I need to eat coating things to make it feel better.

HI,

Not trying to be negative, but erosion is very rare. Fielding is one of the best. It could be a leak in the tubing or pouch dilation or esophageal dilation or a slip (posterior) which would not be seen on a barium swallow and flouroscopy. It may also be nothing. I speak from experience since I have had every lapband complication known to mankind and even though I was extremely successful with the band, had to have it removed due to chronic GERD, esophageal dilation, pouch dilation, concentric slip, posterior slip, psuedoachalasia of the esophagus etc. I revised to a sleeve three months ago.

TO answer your question, it would be hard to get insurance to pay for removal or revision if there is no proof of a complication. Proof requires testing and evidence either with flouroscopy or endoscopy. Without some kind of evidence it would be hard for insurance to consider any revision. At the time of my revision, I was no longer qualified based on a 40 BMI or a comorbidity, but I did have proof of dysphagia and a band slip.

Babs
334/205/150

Thanks for your response. I am aware that erosion is a very rare occurence, and of course I know Fielding is one of the best-that's why I used him! If I were to have an erosion I certainly wouldn't dream of thinking it were his fault, the band simply doesn't work right for certain people for whatever reason. I know that I was fighting tightness most of the year that I've had the band, and despite the good care I received from Fielding and his staff, I did vomit a lot (unfills didn't unfill me enough, or immediately after a fill that made me too tight) and my pouch was irritated probably about 85% of the past 8 months. It has nothing to do with Fielding not be as good as he is known to be. He is great. Really. It just happens sometimes.  Either way, to clarify, I'm not in any way considering revision unless it is absolutely necessary. I am aware of the fact that sudden loss of restriction, especially after an agressive fill can be a bad sign. It is not a leak because he checked at my last fill and all the saline was there. If I were to find out it was only a slip that can be fixed non surgically I would be beyond delighted. At this point I don't think it's possible that it's nothing, but hey, that would be awesome. I'm way ahead of myself here, but I wanted to know, IF it was proven that something was wrong with my band would insurance cover revision even though I'm no longer morbidly obese?

I need a revision as well.  I am going from a vbg to a ds.  Anyway I am hoping for as much.  My concern is also what qualifies one for a revision.  The outlet for my vbg is intact .  There fore no restriction.  However, that is no restriction for ice cream, mush foods etc.  My BMI is 50. with comorbitities.   Am I hearing you all say as long as the surgery is intact a revision is not covered.?

Depends on insurance company. I'm VBG to DS revision, and just had to meet the insurance standards for surgery and scream a bit. Was 267 #, over 40 BMI with no comorbitities and no staple line failure. The vertical banded gastroplasty has a big failure rate (if we knew then what we know now) so revisions are a possibility.

Hi Julie,

To answer your original question, yes insurance would most likely cover a revision even though you are no longer morbidly obese provided that your present insurance (if it different than what you carried when you had the band) does not have an exclusion or that your existing insurance does not have a "one weight loss surgery clause" . What I mean is some insurance policies say that they will cover the original surgery but will not pay for a second surgery. Also of course you would have to prove there is a problem as mentioned before. The criteria for revision is different than a virgin surgery if the band is causing you problems or needs to be fixed. At least in my case, I had chronic problems that became worse over time so the removal was emminent, but I wanted to have revision in one step and I also wanted a VSG which made things complicated. I did get approved without an appeal, but some folks have difficulty getting a VSG approved even as a virgin surgery, so when I submitted for the revision, I made it clear that I could not have a RNY because of my need to have anti inflammatories and that because of my lower BMI , I would not be a good candidate for the DS. The VBG was an antiquateed surgery and would not be good for me either. I would highly recommend that you get a one step revision. THe problem with a two step is that you might have to requalify as a virgin surgery and then you would have trouble with your lower BMI.

I hope that helps in some way!

Babs

That is very helpful, thank-you! (My problem wasn't changing insurers that have clause about previous weight loss surgery-I have the same insurance but my doctor is no longer in network with them. I also don't think they have a one weight loss surgery clause, so I guess I should be good to go should the need arise. Thanks again!)