How can I get insurance to pay for revision?
I had the Lap Band in May 2007. Started at 242 and am down to 184... just found out today I have a stretched pouch...seriously considering revision. I'm just not sure the Lap Band will get me to goal...I'm a slow slow loser and am finding it harder and harder to control my hunger as the months tick on. To top it off the results haven't been exactly what I hoped for and now I'm starting to feel hopeless again...
Did anyone have their insurance pay for a revision? I was told that I needed a pre-determination and it would be covered. I have United Health Care.
Did anyone have their insurance pay for a revision? I was told that I needed a pre-determination and it would be covered. I have United Health Care.
mew6495
on 9/3/08 8:39 am - MI
on 9/3/08 8:39 am - MI
I am going through the process of a revision from an RNY I had in 2001. My insurance covers revision but the issue I have is that they will not certify payment up front. They keep saying my plan covers if it is medically necessary. That is such a wide spectrum.
I would suggest by starting with your PCP. Have him/her run some tests to try and determine why you are not loosing and if there is anything wrong internally with your band. If he has the documented proof of revision necessity then there should be no problem with insurance approving you. But every insurance is different and I would also call them to find out what their exact criteria is for revision approval.
Good Luck to you.
I would suggest by starting with your PCP. Have him/her run some tests to try and determine why you are not loosing and if there is anything wrong internally with your band. If he has the documented proof of revision necessity then there should be no problem with insurance approving you. But every insurance is different and I would also call them to find out what their exact criteria is for revision approval.
Good Luck to you.
Hi,
I have UHC PPO and I am a revision from lapband to sleeve. However, I was very successful with the band and lost 92% EWL at two years out when the problems started. Pouch dilation alone is a sign of a too tight pouch and chronic pouch packing. This is not necesary a band related complication so they may not approve a revision based on this criteria. In my case I had the following problems: esophageal dilation, I had a partial prolapse, band slip, pouch dilation and esophageal motility issues due to having the 9.75 Inamed band from 2003 which was too small for my original anatomy. My insurance was OK with the removal due to medical necessity, but less enthused about revision. It took them 2 weeks to make a decision even though I was suffering and couldnt swallow anything without it getting stuck.
I know they wanted to turn me down. Precert kept coming back and telling me it was escalated to the medical director, an external representative bla bla bla. They even said they contacted my HR dept to see if they would approve and when I contacted HR, they told me no one from UHC had contacted them and flat out lied about having this conversation with HR. Anyway, I got it approved but I didnt want you to be dissapointed if they dont approve yours. INadequate weight loss and pouch dilation may not be enough to get a revision approved since the solution for pouch dilation is to empty the band and let the pouch go back to its normal size.
Babs
I have UHC PPO and I am a revision from lapband to sleeve. However, I was very successful with the band and lost 92% EWL at two years out when the problems started. Pouch dilation alone is a sign of a too tight pouch and chronic pouch packing. This is not necesary a band related complication so they may not approve a revision based on this criteria. In my case I had the following problems: esophageal dilation, I had a partial prolapse, band slip, pouch dilation and esophageal motility issues due to having the 9.75 Inamed band from 2003 which was too small for my original anatomy. My insurance was OK with the removal due to medical necessity, but less enthused about revision. It took them 2 weeks to make a decision even though I was suffering and couldnt swallow anything without it getting stuck.
I know they wanted to turn me down. Precert kept coming back and telling me it was escalated to the medical director, an external representative bla bla bla. They even said they contacted my HR dept to see if they would approve and when I contacted HR, they told me no one from UHC had contacted them and flat out lied about having this conversation with HR. Anyway, I got it approved but I didnt want you to be dissapointed if they dont approve yours. INadequate weight loss and pouch dilation may not be enough to get a revision approved since the solution for pouch dilation is to empty the band and let the pouch go back to its normal size.
Babs
Hi,
I wanted to add that you need proof of a complication. Mine was documented with flouroscopy. It was clear my band had slipped, thus causing trouble swallowing. Another band for me would more than likely cause similar problems due to esophageal motility issues. I had a high pressure band it caused lots of damage to my stomach, liver etc and needed to come out. And due to the fact I took NSAIDs for degenerative disc disease and and had spinal cord compression due to a car accident last year, meant that I would not be a good candidate for another band making it easier for me to get an approval for a VSG.
Babs
I wanted to add that you need proof of a complication. Mine was documented with flouroscopy. It was clear my band had slipped, thus causing trouble swallowing. Another band for me would more than likely cause similar problems due to esophageal motility issues. I had a high pressure band it caused lots of damage to my stomach, liver etc and needed to come out. And due to the fact I took NSAIDs for degenerative disc disease and and had spinal cord compression due to a car accident last year, meant that I would not be a good candidate for another band making it easier for me to get an approval for a VSG.
Babs
Hi;
I had the band in 2004...due to problem after problem I am having a revision to rny also...I also have UHC. My info was just sent into them today...so I will let you know what happens!! I was told it had to be medically necessary and since I have gained back all my weight and am back on my blood pressure and diabetic meds, its necessary.
Hugs
Charlene
I had the band in 2004...due to problem after problem I am having a revision to rny also...I also have UHC. My info was just sent into them today...so I will let you know what happens!! I was told it had to be medically necessary and since I have gained back all my weight and am back on my blood pressure and diabetic meds, its necessary.
Hugs
Charlene
Hi!
I am a band to ??? revision (haven't decided yet what to do). I have UHC Premium PPO through my employer, who is a medical school. I called and gave them the CPT codes for the Bypass and Sleeve and they were both covered. They cover WLS even if it is considered investigational. She told me that there has to be a per-cert (duh, LOL!) and that the doctor has to put in the letter that it's medically necessary. I asked her about a specific BMI, she said MO. My BMI is over 50. Other BMI's if you have other co-morbidities. Anyways, I don't know what your BMI is now, but that could be a factor. Just so you know, at my previous employer I had UHC PPO and there was an exclusion in the plan for WLS. I think it depends on the employer and what guidelines they choose with your particular plan. The best thing is to get the codes, call the insurance company and talk with them. As you'll read, a lot of people have their revisions covered by the insurance company. In some cases it's fast approval, in others it's a long drawn out process. Whatever the case, keep your chin up and don't give up. Best wishes :)
I am a band to ??? revision (haven't decided yet what to do). I have UHC Premium PPO through my employer, who is a medical school. I called and gave them the CPT codes for the Bypass and Sleeve and they were both covered. They cover WLS even if it is considered investigational. She told me that there has to be a per-cert (duh, LOL!) and that the doctor has to put in the letter that it's medically necessary. I asked her about a specific BMI, she said MO. My BMI is over 50. Other BMI's if you have other co-morbidities. Anyways, I don't know what your BMI is now, but that could be a factor. Just so you know, at my previous employer I had UHC PPO and there was an exclusion in the plan for WLS. I think it depends on the employer and what guidelines they choose with your particular plan. The best thing is to get the codes, call the insurance company and talk with them. As you'll read, a lot of people have their revisions covered by the insurance company. In some cases it's fast approval, in others it's a long drawn out process. Whatever the case, keep your chin up and don't give up. Best wishes :)
You can go one of two ways 1 call and ask about surgical wls revision , or 2 let the surgeons office call and see if they can get the info ..
Aetna paid for mine. I had to send in a detailed letter. was a little wait ,,,criteria was strange ..
Good Luck and keep us posted
Aetna paid for mine. I had to send in a detailed letter. was a little wait ,,,criteria was strange ..
Good Luck and keep us posted
GinaU aka Jeanna
RNY revised to Extended RNY 5/2008
Total loss 181 and counting
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