Penn. Highmark BCBS ins.?

 Does anyone have this ins.?  Just wondering what your experience is with revision?  Thanks!!

Oddly enough, I was just looking over their policy this weekend as part of my appeal on my revision case. From what I saw their policy is this:

Reoperation may be required to either “take-down" or revise the original bariatric
procedure. Surgical revision or reversal (i.e., take-down) is covered for members who
have complications from the primary procedure demonstrated by diagnostic study (e.g.,
obstruction, stricture, dilation of the gastric pouch). A reoperation or reversal is
considered not medically necessary unless the primary bariatric surgery has resulted in
complications, and therefore, it is not covered. (See Medical Policy Bulletin Z-35 for
additional information on repeat surgical procedures.)

Not sure what kind of revision you want but they appear to exclude the sleeve (that's what I'm getting).

Here's where I found their policy:
http://weightloss.clevelandclinic.org/images/file/Insurance% 20PDFs/HIGHMARK%20BCBS.pdf

Not sure if that helps or not. I also got the standard of care for bariatric surgery from the ASMBS over the weekend and they clearly state that revisions should be performed upon failure of primary surgery. I used that in my case too :-).

Britt

 Thanks for answering Britt!
I am going from the "band" to the "duodenal switch".  I don't nderstand any of that-it's all jargin I don't get! lol  I got all that in the mail and even had the guy read it to me over the phone, and I'm not a dumb person!!  Well, until now!
I've not lost any weight  in 2 1/2 years with this band despite trying everything I could and it was suggested it's a "metabolic" issue and won't work......uhgggg

Well it sounds like you'll qualify to me. Basically the policy means that the original surgery had to have a problem for them to revise it. Some insurance companies will still cover a revision if the only problem was no weight loss. Highmark has really hardcore restrictions for bariatric surgery but if you qualified for the band you'll probably be fine.

Britt

Hi, Would a gastric fistula be considered a problem enough to approve a revision. I have Health America and just got turned down for the repair because they have changed their policy to not approve any bariatric surgery or revisions. I also have Medicare as secondary but not sure if they would cover it and wouldn't know until after I have the surgery. I could get stuck for the entire bill. I found this out today, just 4 days before my surgery was scheduled so had to cancel the surgery, I had gone to the surgeon thinking I had an ulcer because of the pain and acid but found out it is a gastric fistula, a staple disruption. Eight years ago when I had my rny they didn't separate the stomach from the pouch. I am in pain and miserable and will probably have to live this way for the rest of my life. I think if it comes to cash pay I will have to wait and sell off a bunch of things and go to Mexico for a revision to a DS which is the type of surgery I want anyway. I am wondering if I could change insurances and get it covered but probably no such luck. I guess the insurance companies are getting harder to deal with, they would rather pay out for the co morbidities than bariatric surgery to make a person healthy. Carole

 Well gee Carole, that sounds like a DEFFINATE need for a revision to me.  Theres no reason you should have to live in misery like that.  I'd raise a BIG  stin****il they did domething!!  

Gosh Carole, I think it'd be worth a fight. Have you considered getting the Lindstroms (ObesityLaw.com) to help out? I'd think you can call Medicare to find out more. The way I understand it though secondary usually only pays for the remaining costs that the primary covers but you never know.

You should be able to change insurances and have it covered but you might have to wait. I'd check any insurance company's pre-existing condition clause and I'd also look up their revision policy.

Whatever you do, get it fixed. I waited many miserable months to have my band out. I could have had the last year back if I'd just paid out of pocket - I wish I'd done it.

Britt

I plan to go out fighting for this surgery. My husband is as upset as I am and he has called the insurance company and his employee benefits office, they told us to appeal, so today we did that. I also emailed the obesitylaw.com site and am waiting to hear back from them. I have no idea what they charge but if its not too high I will go with them too.
I am sorry about your band, it must have been horrible. But I can imagine out of pocket would have been costly. If I change insurance that isn't where my husband works (the state) then that insurance would be secondary to my medicare, thats how it was before I got married. The odd thing is it was Health America that did my first rny and I cannot see why they would not do a repair, thats like saying sorry, you have a hole in another organ but you will just have to live with it. I am still regrouping and figuring this out as we go along, somewhere something will have to happen. Carole

In case it helps, the Obesity Law folks are really reasonably priced - just a flat fee for an appeal. Far less than any other legal help I've paid for in the past.

Britt

Ronda, I would prefer to have the DS too. Especially because as we age we need meds for arthritis and with the rny we cannot take anti inflamitories. That is where I am right now, all I can take is Celebrex and Ultram and it doesn't do all that much for the pain. I think the DS is so much more natural to our bodies and just makes more sense. If I had the money I would be having the whole thing revised to the DS. Carole