Opinions Needed - Insurance Question

Hello Everyone.  I'm new the board and was hoping that someone(s) may be able to provide some insight into the whole Insurance - revision dynamics.

I currently have BCBS ppo.  In 2001, I had a gastric bypass.  At almost the year mark, I began gaining the weight back slowly.  My lowest weight was 165, my highest was 175 and I'm now up to 263 (BMI 39).

Over the past 9 years, I have tried all sorts of things to lose weight and have failed.  After doing some searching on the internet, I am now pursuing a revision.

Here is what has happened to date:
I researched and found a good surgeon that specializes in Gastric Bypass and Revision surgery.  

I requested a copy of my pre-op report and submitted the information along with the new patient forms (there were a ton).

The surgeon's office contacted my insurance (for which the surgeon just happens to be a preferred provider!) and confirmed that revisions are covered and I believe discussed under what cir****tances.

I was given a prescription for an Upper GI - which I took at a locale hospital's radiology department. 

After review of the report and the pictures that was provided to him from the hospital and the attending Physician, the surgeon scheduled me for an endoscopy at another local hospital.

I had the EDG today and I am now looking at the pictures and the information that he provided to my parents while I was still knocked out in lala land.

The EDG shows:
1. An enlarged/stretch pouch (both in width and length)
2. An enlarged outlet (is this the same as stoma?)
3. A hiatal hernia (which I guess explains why I sometimes wake up choking)

Other issues I now have:
1.  Diabetes, which I did not have before. I'm currently on meds as of recent
2.  Insomnia, I also have meds for this

So - having typed all of that.  Does anyone know what I should expect?  Is it likely that my insurance will deem these appropriate reasons to have the revision?  I know that no one knows for certain but I was just wanting opinions.

 

 

Your story is similar to mine, and I hope your revision outcome turns out better than mine!

If your surgeon does a full ds revision, awesome!  If not, find one who does!

Best of luck.

Hi,'I am currently in the research mode for a revision. What kind of trouble did you have? I am finding lots of positive things but not a lot of negative ones. I am trying to find some of them.
Thanks in advance. I am seeing my doctor on Wednesday so any help would be great!

hey,

I had a pretty uneventful surgery.  I did require 2 units of blood, and had a little problem with low potassium.

The trouble came after surgery with wound issues.  It took from March until October for me to heal completely. The trouble really is in the type of revision I had, the erny, or distal, my doctor even calls it the ds, bowel only.

I have a 120 common channel.  My problem is that I have alot of trouble eating good quality protein, like steak.  It has always hurt my pouch and I can never keep it down. Chicken does the same unless it is fried.  I can eat a decent amount of food compared to some rny's but actually not too much. Example, a half of a steak house type burger is all I can handle.  It fills me up, but the problem was/is it doesn't stay with me.

I have an enlarged stoma, and history of ulcers in the pouch and on the stoma.

With an erny you need alot of protein, and I most always have to use shakes, which give me horrible gas and such.  I have tried many brands and even the lactose free ones do a number on me.

I started out at 238, and today at 14 months out am at 188.  Not what I expected!  154 would put me at a "normal" bmi on the charts.  I have been petty compliant to eating the way I am supposed to, protein first, and complex carbs,  with now and then treats.  Right now I have totally cut out even the complex carbs and am on basically an atkins diet.  I still am not loosing.  I bounce around about 3-5 pounds. 

I just want people to research for themselves. Do not let others convince you. 

But I will say that if you have issues with your pouch, do not get a revision that does not address the pouch!

I wish you the best, keep reading and you will know what to do!

Shele:

How are you? I'm not on here much anymore...But browsed through and saw this post...How are things going for you?

JRolfson

Hey Janie!

I am doing ok, stopped loosing, no matter what I do I don't loose.  I just finished 2 weeks of atkins induction and did not loose a pound...ugh!  But I don't have to watch what I eat so far I don't gain so ..

Labs were not too bad, but def going down.  The worst being vit D it is 25, and pth is messed up.. so doc said my calcium was low, but shows ok becuse I am loosing bone??? IDK,  he has me re-testing in 3 months to see what it is doing.

Still have some pain, but it doesn't get worse, just anoying. I think it is a hernia, doc says it shows a small one on ct scan.  My energy seems pretty good, def better than before the revision.

Just wish I could loose the last 35 pounds.  I am in a size 12 on bottom and L to xl tops... still not bad but not what I want!

How about you? Are you still looking into the DS?

Did you go online and check out your specific BCBS guidelines for revision?
Does your company have a WLS exclusion?  (some offer a 1st but not a revision!  that is the case with MY BCBS policy)

Do you know which procedure you would like to revise to?

My opinion based on my experience and research:

Rny to a tweaked Rny =  repeat in the future of what you've got going on now

Rny with BOB = possible issues associated with all the Band stories from hell and then you have limited restriction without any additional (and often very necessary) malabsorption.

Rny to DS =  BINGO!!!  Best stats for promised success.  Go to www.dsfacts.com

Good luck!  I just had my SECOND revision 2 weeks ago.  ERny to DS!!!  Wooo Hoooo!  I finally got it right!  LOL!  Unfortunately I had to live with the Revision from Hades to complete my path!

Hi Joyce, I was wondering if you would know about how to find an insurance company that will approve a revision to ds? I had an rny in 02 and now have a gastric fistula, the insurance company Health America, turned down my request to just repair it and they had okayed it in 02. They said their policy has changed. I am now thinking of trying to find new insurance other than my husbands. I have medicare as secondary right now but if I go out on insurance of my own then it will be come the first. I am 65. I don't know which way to go but I really need something done, I would prefer the ds to an rny repair. The surgeon I go to doesn't do the Ds but I would change drs in a heartbeat if I could get the right insurance. Any suggestions? Carole

Ahh Carole I wish I had a great answer for you.  I guess you might try this route.

1.  go to the www.dsfacts.com list of surgeon's and fine the one nearest you.
2.  Call their office and tell them your situation.  Ask them to recommend a Self Insured plan.  When I was working in a Bariatric office, I had that question all the time and had a list near the phone to tell people.  It was quite a while ago and I think they were all AZ companies.
3.  See if "Any" Ds surgeon's accept Medicare beffore you proceed.
4.  Find out about financing (Care Credit, etc) and what a cash price would be.  A car payment type amount per month may be your only ticket!

and lastly....You could appeal that if your insurance covered you once and you are still in "need" that they should cover you now.  Appeals can work.  It did for me!

Good luck friend!

My insurance does have a provision that states that it will cover revisions.  I'm just having a hard time trying to decipher whether my conditions(s) are serious enough to invoke the coverage..  I know that prior to ordering my Upper GI they coordinator for revision patients directly spoke with my Insurance about their requirements for coverage.

I also need to obtain a breast reduction - for medical reasons.  But, I don't want to do the BR if I am going to have the revision done.  I would rather weight until after a significant amount of weight loss.

I wont know what the Surgeon is suggesting until I go in to speak with the Surgeon on July 15.