Insurance documentation for revision - need help and input

Hi everyone,

I am in the process of starting to gather information to be submitted to insurance for approval of a revision from Lap Band to DS. This is what my insurance policy states to approve a revision surgery:   Revision of a failed obesity related gastric procedure may be considered for reimbursement when documentation demonstrates failure of the initial surgery. Surgical failure may include, but is not limited to, development of a fistula, improper construction of the initial bypass (e.g, gastric pouch is too large), obstruction or disruption of a suture/staple line or recurrent slippage of an adjustable gastric band.   Medical record documentation must include all of the following:  

• Cause of surgical failure, and
• Medical necessity of initial bariatric surgery, and
• Progression of weight loss beginning with the date of the initial surgery (prior to surgical failure); and
• Compliance with recommended post-surgical diet, exercise and behavior modification programs

  I recently had an upper GI which showed “the band is in proper position at 45 degree angle and that near the lap band there is mild funneling which is suggestive of flow restriction". Doesn’t seem to help my case as it didn’t show the band slipped. The doctor told me it looked like I need a fill although at last fill had 3.9cc in a 4cc band.   I also had an EGD which shows esophagitis and a small hiatal hernia. In the report it states “On retroflexion from the stomach, there was no obvious evidence of lap band narrowing area.   The funds of the stomach appeared normal and the GE junction area appears normal except for a small hiatal hernia appearance. There was no ‘hour glass appearance’ sometimes seen in the patient with lapband. There was no erosion of significant mucosal abnormality in the upper portion of the stomach."  I asked the doctor what he meant by “no hour glass appearance" and he said there was no definition between the band above the pouch and below. There was no defined small pouch.    I have my band almost filled to capacity (3.9cc in a 4cc band). Food constantly gets stuck and I vomit often at the beginning of a meal - sometimes 2-3 times. After that I can eat a lot of food with seemingly no restriction. I have done this when my band has been filled at many levels.  I’ve always had little to no restriction. Wouldn’t that be considered surgical failure? The damn thing has just never worked. Can the surgical failure be that someone loses very little weight? Also the fact that food constantly gets stuck no matter if I take small bites and I chew well?   I am sorry this is so long. I was just hoping to hear from other lap band to another WLS people and what got them approved for a revision. I
  I am really getting worried that the insurance company is going to deny me.  Thanks for reading and for any input!

My first lapband was a 4cc band. I did okay for the first 6 months and then was just never "right". If my band was completely empty I could eat everything. With just 1/2 cc's I couldn't swallow water. I had a scope done and my surgeon, not the original one, said that my band was too small and had slipped. I decided to give the band another try so I had the old one replaced with a 14cc band in February of this year. Well, I am having major issues with this band as well and my surgeon and I have discussed my options and I will now have a revision over to a bypass. My second band hasn't slipped but it has failed because I have not had any success with it. My surgeon has documented all the issues I have had and all of the changes I have made with little to no results. I was so afraid insurance would deny me because my band was right where it was suppose to be. To my surprise, my insurance approved me within a week.

Talk to the program coordinator where you had your surgery. They know what to write when submitting your info. to the insurance companies. They may be able to advise you on what you should do. Again, I thought I would be denied and that was not the case at all.

Good Luck and don't get discouraged!!

Jenn

Hi Jenn and thanks for sharing your story.  It gives me hope that I might be approved without many hoops to go through.  I am sorry you had to go through the band thing twice. 

Best of luck with your revision surgery!

Do you  have to submit to insurance for revision or does your surgeons office submit.  I had a revision from the band to VSG and my surgeons office submitted everything.  They have all the documentation. so it seems like they should know what to submit to try and get you approved. 

The surgeon's office will submit the documentation to my insurance company and I am not even at that point yet.  I am always too far into the future with things and this is no exception.  I just want to be prepared for whatever, if anything, they throw at me to produce.  Thanks for responding.  I appreciate your comments.

Hi Joyce,
I had the band in june of 08.. I had all the problems you had.. In Dec  of 09 I started to get bad pain and had an endoscopy which showed my band eroded... I told the dam dr it was too tight and I could not swallow food.. So after the band wasd removed I waited 4 months called my BCBS  AL  and said I want my new surgery .. I want the vertical sleeve.. They said  "
OH i am sorry but you got the band in june of 08 and we changed the laws in Nov 08  You can have a new weight loss surgery as long as you NEVER had the Lapband"
.. aint that some **** I am still fighting them and I wont quit and i  will jump through all the hoops....
my name is  Rose, email me me any time... [email protected].....

Yep, lots of ins co's are going the route of 'one WLS in a lifetime.'  That' is why I encourage everyone to get a revision as soon as they know they need it to prevent this very problem.

Sadly, the ins co has the right to do this.

In a way I can't really blame them.  I see so often on the band boards...."if it doesn't work I'll just revise to something else."  Would they say that if they were self pay?