Revision from Lap Band to RNY or VSG - BCBS Federal Approval Questions

Hope everyone is have a great Saturday out there!!!

I'd like to know if someone out there has the same insurance as I do, had any problems with approval from the BCBS Federal for there revision surgery?   Monday I plan to call them and ask if  they do cover VSG.  Here are the requirements for Gastric Bypass :  

1.  Must have BMI of 40 or 35  w/2 or more co morbid conditions, hypertension, type II diabetes, high cholesterol, sleep apenea.

2.  5 year history - Medical Documentation of being overtweight.

3.  6 month diet, prior to surgery, which is non surgical, under the supervision of a physician,  using proper diet, weigh****cher, Jenny Craig, Medifast, etc and a exercise workout documented.

 I have read on the VSG forum that they do not cover VSG.  I have been really looking into it.  It seems like something I would want to get instead of a RNY.   My doctor of choice right now is Dr. Lana Nelson, in Norman, OK.   Feb 16th I have my 1st appointment with Dr. Nelson.  I can hardly wait to see what her suggestion is.   

My BMI is 38 and I have high blood pressure, high cholesterol and type II diabetes, possible sleep apenea.

With the lap band I only lost 3 lbs with it, had the surgery April 08.  

Thanks for reading and thank you for replying........          

Virginia, where are you getting your info? The 2009 brochure for BCBS FEP BASIC does not say anything about a 6 month diet or 5 year history. I had my revision from lap band to RNY on Aug 1 2008 and didnt have to provide any of that stuff. They may have a requirement on how long you have to wait after the first failed surgery although I didnt see anything in the 2009 brochure about it.Scroll down to page 52.


http://www.fepblue.org/benefitplans/2009-sbp/SBP2009Brochure _English.pdf

I spoke to a BCBS Federal customer service rep called that 1-800 number in back of our ID card and she digged a little deeper for me.  That is what she found.  It could be that the brochure does not show these requirements.  Who knows.  I will ask my doctor who is an in network provider, I'm sure she should have a better idea then I do on what's going on.  

I opened up the website you gave and read what it says and made a copy of that page and on how to get approval for your hospital stay on page 15.  I will take this info with me to my doctor's appointment.   

It's seems to me that I should have had this surgery last year instead of now.  There's nothing I can do about that now.   I will let you know the outcome.  I have my appointment 16 Feb.   

Thanks again.

Hi, Virgie.

I can't answer your insurance question, but I wonder if you've looked into the Duodenal Switch surgery (DS)? It has the best long-term excess weight loss statistics, with the highest resolution of co-morbidities. You will likely be off all diabetes meds before you even leave the hospital.

You won't get that with the VSG (which is a restrictive-only surgery). Many insurance companies will now cover the DS ... since medicare now does.

I welcome you to the DS board to ask some questions.

One thing. Your doctor isn't a DS surgeon, and may give you inaccurate information on the surgery. Please do research on your own, and make your own mind up about what surgery you'll be able to live with, post-op. Read the posts on the DS message board, and browse through this site to find out the facts:

http://www.dsfacts.com/

Good luck with your journey, Virginia! All the best!

Kathy

So, what happened? Did you get approved and have the surgery? Did it work?

So sorry I'm answering you about a 1 year later.  The answer to your question is NO.  I did not get approved for the Sleeve and so I paid for it myself (loan out of my 401K).  However it was not the right surgery for me.  Not only did I never get to my goal with the Sleeve, I gained most of my weight back.  With the Sleeve, I started to have a big craving for sweets that I never had before, even before the LB.  I also have had SEVERE ACID REFLUX!  I have the big Hiatel Hernia which kills me whenever I eat spicy food, which I love so much.  The LB and Sleeve makes your acid reflux so much worse.   

Ok so now I'm in the process of getting the Gold Standard RNY.  This surgery is covered by BCBS Federal.  I heard that Revisions are matter of medical necessity.  I went to see the surgeon that an old friend of mine went with.  She by the way is still very healthy she lost about 100 lbs back in 2003.  I was very reluctant and chicken back in 2008 when I got the LB, I should have had the RNY and I would have saved my self from wasting money, time and would not have had this HORRIBLE Haitel Hernia either.  Oh well that's the past. I'm going to see the psychologist and dietician on 10-23-13 and then my packet can be submitted for approval to BCBC Fed. I have been praying if this is God's will for me I will be approved.  I will keep you updated.  Best wishes to you, on your journey!     Virginia

I would just like to note,  Not all surgeries work for everybody.  

Also I have seen people with Haitel Hernia's with all WLS and No WLS. Many RNY's at support have had Hernia's.  So you most likely would have had that at some point anyway. Bands do seem to have a higher % than other surgeries tough.   We also see more revisions here with failed RNY than VSG but, I would have to guess that it is do in part to there being more RNY's done and for a much longer time.

Hopefully you are able to see your psychologist regularly this time an get you issues with food worked out.  I am working with mine this time around and it is making such a BIG difference.    Good luck to both of us this time around.

I agree all surgeries do not work for everybody.  I'm not surprised that my Sleeve doctor did not tell me the Sleeve would not help someone that has a Haitel Hernia.  The Sleeve was new back in 2009 and that was his main surgery the he did and I did self pay.

I am going to keep working with the psychologist to completely stop the emotional eating.  Thanks for shimming in and sharing.  Best wishes to you too!

Babygirl, you mean you had the HH before he sleeved you, I figured it was from the band, and didn't repair it when he sleeved you?  That is a given that it has to be repaired.  That is almost malpractice.  You must have gone thru hell. You poor thing!  Big hug

Keep in mind on the insurance, even though you have the same company / type of BCBS plan each employer can elect certain procedures to be covered or not.  For example my friend and I both have BCBS National PPO / EPO  - with my plan everything has been covered even the fertility treatment my husband and I tried years ago.  Her plan does not cover fertility treatment.   Think of it like an ala-cart menu where the employer selects the basic plan and then upgrades to decide how much additional they will pick-up; makes a difference in what the company & the employee pays out.