Define "medically necessary" please?!

I just got a denial letter from BCBS of AZ for my revision from Band to DS because they said that the info they received does not make them think this revision is medically necessary.  I'm going to call the surgeon's office first thing tomorrow AM...but I was wondering if any of you could tip me off on what your "medically necessary" reason for revision was that your insurance approved? 

Technically I don't have a medically necessary reason.  I didn't lose weight because my band is full and I have no restriction.  So it's not doing anything.  My surgeon originally said she could SAY that there was pouch dilation (even though there is nothing but her word to prove that)...but apparently that wasn't done in time for the insurance.  I'm hoping she can send that in and we can try again for an approval...but in the mean time anyone's input would be appreciated.

Thanks!

Sadly, not losing weight does not equal medical necessity.  My band had to come out because even when it was empty, it caused unbearable acid reflux.  When there was fluid in the band, I would vomit several times a day.

The only way to stop the vomiting and reflux was to remove the band.  Not losing any weight (I lost like 15 pounds with it - I had the band for 8 months) was just adding insult to injury.  I didn't lose because I wasn't eating much at all.

I went through some tests that confirmed that the reflux was aggrivated by the band, too - the scope, barium swallow and upper GI series. 

My surgeon's office took care of everything for me, I don't know what was submitted.  I didn't have to redo anything like the psych eval or the 6 month diet.   I just showed up at the hospital on the dates they told me to - I had the band out then the RNY a month later, to allow my stomach to heal from the reflux.  I was very lucky!!

Good luck to you.

I'm sorry about your acid reflux, i've heard so many people with that problem.  Luckily I don't have that.  I'm grateful that I don't have the problems many others do...I just hope that my surgeon can convince the insurance that all of my original co-morbidities aren't being resolved and so in that sense, it's medically necessary...but we'll see.  Thanks for the response :)

I have BCBS of AZ as well.  They approved my revision, I still have high blood pressure and cholesterol as well as horrible acid reflux.  When I went in for revision they were not able do to it, my band had slipped really bad, they removed my band and I have to wait until the end of December.  I just found out that I have to go through the approval process again.  I hope to hear something soon, I am on pins and needles.  Do you have any co morbidities and did they pay for you to have the band in?

Oh yikes!  How frustrating.  I do have all of the original co-morbidities that I had when they approved me for my lap-band surgery.  So I'm sort of hoping that my surgeon can use that.  And they said that a dialated pouch is a medically necessary reason so I'm not sure what "proof" they require, but I'm hoping a suregeon's note will sufice.  Best of luck and thanks for responding :)

They want there to be a reason that the band is being removed. I had reflux all the time. Even if I had no fluid in the band I had reflux.  My band could not be tightened any more. I also started having extreme pain around the stomach/band and threatened to remove the band.


Tamara

Did they check your band for a slip? I got a terrible erosion, my doctors first, and the only sign something was wrong was that he was filling it all the way and I didn't have restriction.

When he discovered it had slipped, he went in and ended up having to remove the band. because there was a hole he was able to decrease my stomach volume as he was repairing the hole, which provided some help and was covered by insurance easily. Not that I would ever wish that on you (or anyone) but if you possibly have a slip/erosion, it's my understanding that sometimes doctors can modify to a sleeve if they're already operating, and insurance will cover all or most of it

Sorry to hear you were denied-  I had mine because of severe reflux and a band slip - the ins orginally approved me for a revision to a sleeve, how ever my surgeon sent me to another surgeon for  a 2nd opinion due to other medical issues I have - he and I discussed all options the sleeve, roux, DS  it was decided with my severe reflux the roux was the best  for me the 2nd surgeon is the one who ended up doing my surgery  so we didi have to resubmit to insurance - they denied it but he sent in a letter and it was approved.....

good luck