Any Band to RNYer's??

Hello :)

I'm looking for people who have had the lap-band and then later turned around and had a revision to another form of baratric surgery.  I'm fighting w/my current insurance company because they say that 'revisional surgery is just too new for them' ... it doesn't matter to them that my band is causing acid reflux, asperated pneounmia etc so what I'm looking for is people to tell me t heir story about their decision to go from a band to rny and what their insurance company qualifications were at that time. 

My insurance company is basically telling me that i may not 'quaifly' for a revisional surgery because my bmi is between the 35-40 mark.  Which is fine however they are saying that my pcos, bmi and seasonal affective disorder aren't included in their "little rule booklet" and the fact that their doctor doesn't even have a though medical history either probably doesn't help!

so I'm writing my denial letter and I wanted to get a feel and understand what everyone else has gone through to go from a band to rny and if they had any issues...I understand that all insurance companies are different but i'm interested in learning on how everything is going with you :)

Thanks!
-erin

I revised from band to sleeve and to be honest I was too ill at the time to fight insurance.  I really didn't have the time required to play the games so I self paid and went back to my original surgeon who I adore and trust.  I probably would have gone that route anyway because there are no surgeons that are on my insurance that I would have trusted anyway.  Not for a revision.

What insurance do you have?

I have ppom or physicians health plan of mid michigan its basically an hmo w/o a referral. They have been nothing but nasty to me and they are making me see an unqualified dr and my dr is the one that 99% of doctors refer to! Any suggestions? I don't have the $$$$

Well, it probably isn't as you say when you write:

I'm looking for people who have had the lap-band and then later turned around and had a revision to another form of baratric surgery.  I'm fighting w/my current insurance company because they say that 'revisional surgery is just too new for them' ... it doesn't matter to them that my band is causing acid reflux, asperated pneounmia etc so what I'm looking for is people to tell me t heir story about their decision to go from a band to rny and what their insurance company qualifications were at that time.

It's not that it is too new for them, I think you explained better here:

My insurance company is basically telling me that i may not 'quaifly' for a revisional surgery because my bmi is between the 35-40 mark.  Which is fine however they are saying that my pcos, bmi and seasonal affective disorder aren't included in their "little rule booklet" and the fact that their doctor doesn't even have a though medical history either probably doesn't help!

All insurance companies have guidelines on what they will pay for and if you don't have the correct BMI and/or comorbidities they aren't going to cover it.  They would probably cover a band removal and that would solve the reflux problems.

Does your current surgeon not contract with this ins co and that's why they want you to go to someone else?  How is this doctor unqualified?

Hi Erin,

I'm a lapband to RNY girl - had my revision surgery on May 19th of this year.  I was having the same issues as you - terrible reflux, regurgitation, etc.  I couldn't keep any solid foods down.  I have Aetna Open Access insurance.  I had a few things going for me:  1- I did well with the band, so it wasn't a matter of "well, this didn't work, let's try something else."  2 - I had a small hiatal hernia which was contributing to the reflux issue and 3 - I have a surgeon who rocks!!  He wrote to Aetna with all my issues and my approval came in less than 2 weeks.  Didn't matter what I weighed or what my BMI was - the bottom line was it was medically necessary to have the band removed, repair the hernia, and revise me so I can continue with my weight loss. 

Keep fighting back!! 

Good Luck,
Debbie

well let me explain further since i realized that I didn't explain clearly.  the band attrubuited to asperated pneounima w/fluid on the lung in november.  i went to a GI doctor who also concluded i had acid reflux and he discovered i had a small hiatal hernia (which was also discovered at the hospital i had gone to w/ the pain became severe and a cat scan w/idodine testing was performed concluding the same). we decided to let fluid out of my band to see if this was causing the issue - it was as is the hiatal hernia ****ep getting acid reflux type symtoms) - fast forward to june when my doctor submitted the paperwork to my insurance company saying that he was 99% sure that if we didn't fix this with a different form of baratric surgery i was probably going to get asperated pneoumina again and i could potentially die if this continued or i would contually be in the hospital.  the denial came. 

my doctor participates w/this insurance company however they are "affiliate" with this hospital called Sparrow Hospital where they practically want ALL of their health insurance mbrs to go.  I refused to go because when i started to get the early warning signs of pneoumina i had gone to the ER and basically was dismissed because "there was nothing wrong with a 25 yo girl having a tempature change from 98.6 to 103". 

So I had a "round" with my insurance company and I agreed to go and see their "high qualified doctor".  My mom and I went and as soon as the doctor came in (I was sitting on the examination table mind you) he went straight to my mom and started asking all sorts of questions about MY band to my mother...when he realized his mistake he concentrated on me.  He never asked any of my medical history, wanted me to tell him about my "band" and then decided that I needed a Upper GI before he was even considering taking me on...two weeks later (mind you I have the band completely deflated and my acid reflux symptoms aren't as bad) I have the upper GI when the guy in charge of the GI was "surprised that there was no acid reflux"...onto the next day when i met w/this doctor and he looked at the upper GI and declared I had no hiatal hernia and that he has no idea what I'm talking about (he's calling me a liar) and that he would "refer" me to their sparrow weight management program.

So, fast forward a few weeks I get a copy of my files from this "new" doctor and he doesn't have a stitch of correct information - my sexual life is incorrect, none of my symptoms are on this sheet, he basically took my 3 year old medical records from my band surgery and slapped in onto his files....and submitted it to the insurance company for "review to perform a revisional surgery" oh and have i mentioned that he's only done about 8-10 revisions and my doctor (which by the way any doctor in the MI area that doesn't perform revisional surgeries) refers all of their patients to my doctor and his group?  And yet the insurance company is okay w/having an incorrect medical file so they can easily deny me for a revision.

I really don't have any money to do a self pay and I really don't know what I'm doing trying to fight this company so that's why I'm hoping to hear the stories of others who have been in the same predictiment (with just not so many issues) and what they did and see if any of their tips or suggestions would help me

phew...i hope i explained that well enough.

HI there!  I am currently headed for a revision, which I will describe in another reply.  But, what I wanted to say to you is that this may be a good case for ObestiyLaw.com. 

I know money is an issue.  But, sometimes a well-timed letter from a lawyer that knows what their talking about it what it takes to shake the trees!!

I wish you well.  I have not begun my insurance fight yet.  I am still in process with my bariatric program's revision requirements. 

Be well,
Jules
Banded 5/19/04 and 5/26/06

Hello all,  I am 5 years post op from my original lap band and 3 years post op from a lap band revision (Standard band to VanGuard).  I originally lost about 150lbs. 

I have had problems with the lap band since the 11th month post op.  I am unable to maintain a good level of adjustment due to my body's reaction to fluid retention (and my propensity to retain fluid frequently).  When I retain fluid (due to my period, the heat, the humidity, if you look at me wrong, or who knows why), my lap band gets extremely tight... often causing an acute obstruction, requiring an urgent trip to the bariatric clinic or to the Emergency room.  I have been admitted to the hospital on several occasions to receive I.V. hydration. 

Finally, after the last hospitalization,  we all decided we had had enough... we have tried to manage this band to very best of our collective abilities.  I have truly given this the old school try.  Because I can't stay adjusted to the green zone, I have gained 40 pounds back.  And when I am close to the green zone, I am in danger of an acute obstruction. 

My bariatric team is calling my situation "lap band intolerance."  The lap band hasn't "failed" because it is my body's reaction to the lap band.  It also hasn't "failed" because I still maintain a 110lb weight loss.  I am in the obese BMI range... but, it is certainly not "morbidly obese" (yet).  That could be a major problem with insurance. 

I am going through my program's requirements to qualify for a revision to a RNY.  I am NOT excited about going to a bypass... I never wanted a bypass.  However, if we just remove the band, I will be right back to where I started and more.  My health is suffering with this weight gain... and I am put directly in the path of a whole host of co-morbid conditions.  A bypass is the natural move when the lap band isn't a good primary intervention. 

We'll see what the insurance says after my program crosses their t's and dots their i's.  I appreciate their thoroughness.  They are doing everything they can so that when the insurance is submitted, we have the best chance of getting an approval. 

Be well,
Jules
banded 5-19-04 and 5-26-06

If you don't want RNY don't get it.  Get a sleeve.  You clearly do well with restriction alone.  You'll have to live with your surgery type for the rest of your life, be sure to get the one you want.

 I wish you luck! I had many issue with the band including slips. Have you checked to make sure yours did not slip? This was where many of my issues came from. I had the band put in July of 2007 and removed June of this year.  I just had RNY last week. I did not have a problem with BC/BS.