May need revision; but now have exclusion any BTDT?

Hi,

I have a realize band.  Have had it for 3 years.  Things up to a few months ago were going great.  I lost 90 lbs, and was maintaining it.  Then I started getting reflux, and could eat way more.  My band had slipped.  They emptied it, and 6 weeks later it looked like it had gone back to normal -- sort of.  I gained 12 lbs in those 6 weeks.  They refilled me half way and I have another appointment in a week or so (4 weeks post fill).  I don't have reflux now, but am concerned that my band will slip again.

If it is, I'll need a revision surgery.  Here comes the problem -- my husband got a new job, with  new insurance, that has an exclusion for bariatric procedures.  If my band is slipped again, can they really refuse to pay, even for its removal?  If you leave a slipped band in, many bad things can happen.  

I'm wondering if anyone has been in this type of situation, and what your outcome was.

Thanks.
Eileen

yep, sorry to say if they have an exclusion for bariatric procedures they can refuse to pay.  Even for a slip.  There is a girl that is self pay, had surgery and her band has slipped and doctor had to empty all the saline out and its just hanging out in her.  She can't afford to have it removed. 

There is a way to get ins to pay for an emergency band removal but if it isn't an emergency, no.

With your BMI even if you didn't have a WLS exclusion they wouldn't pay for a revision anyway. You'd be self pay.

It was my understanding that since the revision would be required due to device failure, then it would be covered (if it were not excluded).  What are you basing your statement on?  It has me worried!

Nooooo, if WLS is excluded it's excluded, period. In an emergency they would pay to remove it but that's it. No repairs or repositioning.

I'd start doing some research now for plan B. What if you have a severe slip and it has to come out? What will you do? Maybe start researching other surgery types and surgeons in Mexico just so if something horrible were to happen, you have Plan B to fall back on. It wouldn't be great at all to have a severe slip and then have to figure out what to do.

Many many self pays go to Mexico, it's really not a bad experience IF you do your research.

What I was asking about was this:
"With your BMI even if you didn't have a WLS exclusion they wouldn't pay for a revision anyway."

Where did you get that from?

I know an exclusion means they pay nothing.  :(  I'm just thinking about getting other insurance.  Your comment leads me to believe that nothing would be covered anyway.

Eileen

They will pay for band removal in an emergency, what you do is pre plan a time with your surgeon to go to the ER and when you are admitted through the ER there is no approval process. You get surgery and it's a done deal. But a revision... nope.

If you are planning on getting a private policy they do not cover WLS at all. Everyone who has exclusions would be getting a policy for WLS and then dumping the policy. No ins co could afford that. WLS is in group policies.

It's just how exclusions work.

If you didn't have an exclusion and WLS was covered, they will not pay for a revision unless you meet all the basic standards anyway such as a 35/40 BMI, etc.

I'm looking into getting cobra, which would not have an exclusion. 

I just reread Aetna's site, and revisioin would be covered, even though I am < 35 BMI:

"Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:

1. Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
2. Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or

3. Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments.

"

I think you have some misinformation on that piece.

I do thank you for the tidbit about entry through the ER.  Makes sense.  I feel a bit better not thinking I coudl get in *real* trouble.

If you have WLS benefits they will fix a band at a lower BMI but they will not switch you to a sleeve (for example).

I'd call them and ask to speak to a supervisor (at least someone who has been there for awhile) and verify.

I'm not sure how you are going to get COBRA if you already are insured under your husband's plan.  COBRA is for when you LOSE your coverage due to job termination, as far as I understand it.  And you have to enroll AND PAY within a very limited time span after your previous insurance terminates.  Finally, whatever limitations you had before you become eligible for COBRA, you have them when you get COBRA, because it is a Continuation Of Benefits (i.e., of the benefits you HAD), not a different plan.

And it is very expensive.  I've been on COBRA for the last 12 months, at my former company's expense (part of my severance package).  I'm changing to my new company's plan next month, so I don't care, but I just got the bill for the COBRA for February for my family that I won't be paying - it was almost $2000/month.

You may be able to get the band out, if you can get a surgeon to say it is medically necessary.  But there's no way I can see that you're getting a revision.