what qaulifies as a medical necessity?

So my insurance (blue shield of ca) only approves revisions if it is a medical necessity.  So my ? is what qaulifies as a medical necessity?  I'm almost 4 years post op and my pouch is definately stretched because I can eat and drink normally just as I did before surgery.  Would stretching of the pouch be a medical necessity?  

oh yah sorry for the double post earlier....thought I was booted off internet

You said your weight is back at 280. That should qualify you for revision. Please consider revision to the duodenal switch (DS). The DS is the best remedy for failed wls.

www.dssurgery.com/about/publications/duodenal-switch-safe-op eration.pdf

www.dsfacts.com

I wish my insurance would grant me the "medical necessity" for my weight.  But, unfortunately, that has not happened.  (You can check my profile) I am now in the appeal process.

I think that your pouch stretching is a GOOD start.  See if you can get in & have an EGD and upper GI with small bowel follow through.  Get those tests done & see if there is a 'mechanical failure' of some sort.


GOOD LUCK & keep us all posted!!!!!!
-Jamie

Mechanical failure is a good way to phrase it. How can the insurance company deny you a correction and/or repair if something went wrong. It is not good for our health. I believe that is the term my doctor used as well............

My Dr. submitted the same thing as mechanical failure of the band. For the past two years he has been trying to correct the problem of the band over tightening, I had a new UGI and yep it is tight but that is not the problem further down beyone the band itself my esophagus narrowed out to 2mm no food passing beyond that. I ahd no symptoms but the UGI showed another mega esophagus, full of food so stretched out that my fill in the band was removed and then he discovered in a UGI from last June 2010 that I have a hernia on top of this. He said the Band needs to go for sure for with the hernia I will always have the problem so no more fill adjustments for me. This is the third time this has happened to me. I am at risk for a lifetime of hurt for now the esophagus is in danger of becoming damaged on a permanent basis and this is not normal nor right, but I have a feeling that the insurnce company will not approve me so I need to know how to fight this denial.

Roxy

My guess would be that you are now obese again. Medical conditions such as diabetes, hypertension etc.....Weight gain, walking issues, pain from the gain......etc...

I had my RNY revision done 4/28/11 - my insurance was a dream. I was approved in 2-3 days. I was amazed. I also had to have a major over haul. RNY revision, hernia repair and scar tissue removal. So that may be why....Plus I had all the testing done to show that my pouch stretched and was no longer working. My doctor said he never saw anything like it. So there are many issues that could lead us to this point. Hopefully you have an insurance that does not have a bariatric clause.

Best of luck....Keep me posted!

Melissa

Thanks everyone :)  I called my insurance and they said its covered but weight gain alone is not a mechanical failure.  I go for an upper gi tomorrow and I just know my pouch is stretched...alot of it probably has to due with my over and drinking with meals. Insurance also said I don't have to go through the 6 months of classes and diet again. So yay to that.  Although I have been excersising and dieting on my own for the past year only to gain weight.  So anyways wish me luck...I'll be crossing my fingers for a smooth process.  I was denied 2 years ago for a revision and never appealed so this time I'm ready for the fight. 

Congrats on everyones progress and thanks for the advice:)