?? on requirements most people face for revision approval

Can anyone tell me the requirements that most people have face when trying to get approved for a RNY to DS? 

I would like to start to look into revision surgery.  I had my RNY surgery 11/2008 weighing 344lbs.    I have seen a low weight of 210 for about 30 seconds.  Today I am ranging about 225lbs.   I have not lost any kind of major weight in months despite diet and exercise.

I completely understand that 119 - 134lbs in amazing. I am so proud of my success so far.  But, I do not feel that my journey is complete.  I am still ashamed of my weight.  Heck, i actually need to lose another 100 lbs just to be a NORMAL weight.

I have Keystone Health Plan East, which is a division of Blue cross.  I have absolutely no issues in getting my RNY surgery covered.

Also, if anyone knows of a DR that does revisions in or around Philly, or NJ area i would so love the recommendation. 

Thank you!

For the most part it is the same requirements as the first time around, bmi of 40 or 35 with co-morbidities.  Letter from PCP of medical necessity is a good first step, then Psych clearance, nutritiionist, Cardiac and Pulmonology clearances and documentation from your surgeon of mechanical failure of your bypass.  Some plans may have a limitation of one WLS for life and others may require additional steps like a six month medically supersvised diet plan.

As for surgeons, the best known in that area for revisions is Dr. Greenbaum in Willingboro, NJ (just over the bridge from Philly) but it seems he is not accepting new revision candidates until January.  Dr. Pomp at NYU can do revisions lap but seems to advocate a staged approach requiring two surgeries to complete the revision.  Dr. Gagner is supposed to be setting up shop in Montreal beginning in July and he also does lap revisions.

forgot to add, Upper GI or Endoscopy (sometimes both) to examine and document mechanical failure of your RNY bypass and rule out other complications.

Great information, thank you so much!

Is Mechanical faliure a major requirement for revision?  If there is not a mechanical faliure do they still sometimes cover the surgery?

From what I have seen if there is no technical or mechanical failure in the existing surgery, they would most likely cite patient non-compliance and deny the revision.

My revision was covered very easily with NO mechanical problems with my RNY. I had no co morbidities and no problems with my RNY. I had regained about 50 lbs. from my lowest RNY weight loss and that is the only reason I went in for revision.

My insurance is BCBS/Anthem and all I had to do for insurance approval was be 2 years out from original surgy and have a BMI of 40 or 35 with 2 co morbidities, a psych evaluation, and a meeting with the nutritionist. That was it. My surgeon on his own ordered the upper GI, endoscopy, and ultrasound of my gall bladder just so he knew what everything looked like before he got in there, but none of that was required my my insurance.

The best thing to do is contact your insurance and ask them exactly what you need as each insurance is different and requires different things.

Good Luck!!!
Nicole

Wow, your surgeon put you under at a bmi of 35-40 without a pulmonary or cardiac clearance?  He was taking quite a risk, I guess the malpractice rates in Utah are much lower than on the east coast....but it just goes to show you, how different things can be from doc to doc an ins co to ins co.  I know when I had plastics in Detroit, the surgeon didn't order pre-op at all and said they were a waste of time, then  again that could be a good part of the reason I need a major revision to those procedures. 

Thank you Nichole... Your story is a true inspiration to me and i hope my journey is half as easy as yours. 

I am getting on the phone today!

I have Blue Cross/Blue Shield of NJ and my revision from lap band to RNY was covered because the band was causing me reflux, a "mechanical problem".  

They would not have covered it solely on the basis I wasn't losing weight.

I wasn't losing weight, because I wasn't eating enough because I was puking all the time due to the reflux....vicious cycle.

I didn't have to do anything.  I had the band in June 08, had it out March 09, and RNY in April 09.  I didn't have to repeat anything, maybe because I was within 12 months of the original surgery date? I don't know and I was glad I was able to just have it done!

I called my insurance company today.  They will cover a second WLS but only if found to be medically necessary.   ie.. Machanical failure.   I guess i need to go see my Family Dr first. 

Anyone have an ideas on some of the complaints i can use to help the machinical failure diagnosis along???