Lapband Removal Approved; Sleeve Denied -UHC

I have been lurking on this board for a while - previously was on the Lapband board many years ago. After having LapBand surgery back in March 2006 the most I ever lost was 44 pounds and I switched doctors in NY to try more fills, etc a few years ago to no avail.  My band was almost 100% full (3.8cc in a 4cc band) yet I had little restriction.  Once they bumped it up to 4cc and I was so tight I couldn't keep water down.  So I basically gave up on it all; felt like a miserable failure and went back to trying traditional diets - Weigh****chers, etc.

 I began researching a revision to a sleeve a few months ago after moving to Florida.  The Dr. ordered an upper GI right away and lo and behold they found that the band had slipped upwards over my esophogaus - wasn't even on my stomach and I had a lot of pouch dilation.  I can't tell you how vindicated I felt after finding that out - after feeling like such a failure for years.  He immediately unfilled my band to allow my esophagus to heal and I have to admit I have immensely enjoyed being able to eat foods I couldn't for over five years - particularly steak, without it getting stuck. 

So my new surgeon wrote a letter of Medical Necessity and I provided my whole file from my last surgery for additional backup to show I had been morbidly obese more than the last five years, even with the band, etc.  I have read many people who said they had UHC and that they got approved quickly so I was pretty positive I would have the same result -- WRONG!

I received two letters yesterday - one saying they approved the LapBand removal - Yea!!! but the other said they did not recommend the sleeve because I had not met their requirements to be on a supervised diet and exercise plan under physician monitoring (and not to be a bariatric Dr.).  So one part of my says, fine, I'll just embark on the 6th month plan but the other part of me says the whole thing is ridiculous.  Why would they expect me to be seeing anyone other than my bariatric surgeon related to weight loss, particularly having a Lapband through all these years.  All of my other Dr's knew about the lapband; my former NY primary Dr. was the one who supported it back in 2006 - but when it came to matters of me not losing weight they expected I was seeing the bariatric Dr. for that - which I was until the last 18 months or so when I gave up. 

Am I nuts?  Has anyone gone through this before - with UHC or any other carriers?  To me having a Lapband was being on a diet program, per se.  I ate mostly slider foods - and yes not the right ones either which caused me to gain all but 12 pounds back.  And I've now gained 10 of those back after having been unfilled a month or so ago. 

I'd love to hear from others on if you ran into this and how you dealt with it.  I understand I could ask for a Peer to Peer review or Appeal the decision.  Not sure which route to go - or if I should just 'suck it up' and begin a six month plan.  Seems silly to me for them to move forward with the Lapband removal and not do the other surgery at the same time - isn't that more costly to them in the end and more risky to me to go through two surgeries? 

I appreciate any responses and support.  Thanks much.

Susie

Susie, 
  I can't give you any advice on your insurance other than appeal!!  I had exactly the same thing happen with my lapband and I just got my approval yesterday to have a revision to RNY :)   We do not have the same insurance but if i were you i would flood them with info. I sent everything i could think of to my insurance company, I went ahead and had my nutritional and psychological, I asked my primary care dr. to write  letter explaining how the slipped band was negatively impacting my life. and i sent all of the records from my lapband surgeon and all of the info from all of my fills.  Hang in there, make up your mind that you are worth the fight and give them everything you can come up with.
Take care
Jeannie

Thanks so much for the good advice.  I called my surgeon's office the other day and discussed with the care coordinator.  I am seeking a Peer to Peer review.  The more I thought about it the more ridiculous it seems that they would have expected me to go to another Dr. and go on a physician monitored program when I had a LapBand and was being seen by my surgeon or periodic fills, etc.  However, just to have a backup plan I did go to my primary Dr. yesterday specifically to begin a six month supervised program and I joined WW Online.  So I won't lose more time if the Peer 2 Peer or appeals don't work. 

I will also ask how much the sleeve will cost above the LapBand removal since at least one inpatient surgery was approved so perhaps the surgeon will let the majority of the costs go towards that.

Thanks to all who have responded.  I really appreciate it and will keep you posted.

I'm sorry you were denied, but you can appeal:

I already responded to a post similar to yours, so I'm just going to copy and paste this:

I'm sorry you were denied.  But please do Appeal!!!!  Insurance often doesn't want to spend money, and they think if they deny people, people will think it's really a NO and won't appeal, but you should appeal.

I appealed and won. 

Documenate your experiences, and a study that gastric banding has low markings, (Shoot, i have the papers but not with me), some posts that I printed off OH and submitted along with the letter, bombard them with all kinds of lapband failure study, etc... Explain your complications.  I have a copy but it's on the computer at work and I'm off tll the 17th. 

Here's the link  that's what I submitted when I appealed.  

http://www.medpagetoday.com/MeetingCoverage/ASMBS/20919

Also when I posted a question on one of the boards here on OH on how people felt about having band removed and revising and they repleid they feel much better, etc..   I printed them and submitted.

I told them about constant regurguation, 5-10 days of good eating a month ... and people looking down on me whenever I puked at work asking me if i was pregnant, worrying if peopple thinks I'm bulimic or something

Also show that DS might be cheaper than lapband, maintenance-wise.  Costs of fills, doctor visits, etc.  How many fills and unfills, etc.  Compare costs.

Also show that any of your co mordibities did not resolve.  My diabetes, sleep apnea, etc did not resolve ... also had high cholestrol.

Also indicate how long you have been overweight .... I have been overweight for 33 years now.

I also luckily saved checks from WW (duplicate checks) in 2002-2003 that I copied and submitted along.

viola.. approved

Good luck!!! 

Hugs!

Unfortunately, I had to delete this post due to privacy concerns.

you might also see what it would cost you for the revision procedure - if your dr does it all at the same time  the insurance approval on the band removal should cover most of the hospital costs and the band removal part. . I am curently on my last month of 6 mo diet to revise from band to sleeve.and a little nervous about what insurance will say - but if they will approve one part of the surgery i will try to find the funds to cover the other. If they deny both its off to mexico for me.

Thanks so much for the good advice.  I called my surgeon's office the other day and discussed with the care coordinator.  I am seeking a Peer to Peer review.  The more I thought about it the more ridiculous it seems that they would have expected me to go to another Dr. and go on a physician monitored program when I had a LapBand and was being seen by my surgeon or periodic fills, etc.  However, just to have a backup plan I did go to my primary Dr. yesterday specifically to begin a six month supervised program and I joined WW Online.  So I won't lose more time if the Peer 2 Peer or appeals don't work. 

I will also ask how much the sleeve will cost above the LapBand removal since at least one inpatient surgery was approved so perhaps the surgeon will let the majority of the costs go towards that.

Thanks to all who have responded.  I really appreciate it and will keep you posted. Susie

I too had a lap band, did great the first 1.5 yrs and then it started, since then I have had a upper GI for clearing on an emergency situation, now no fluid in my band and up 72 pounds.  Wow, what a disappointed.  Today I am home sick since I still get food stuck and last night it was really bad, having trouble with fluids today.  Miserable.  Now here is the kicker, I changed companies and my new company doesn't pay for obese benefits and Atena will pay pay for removal but NOT the revision.  Well I am facing a 12, 500.00 cash bill and now am facing 2 surgery's with the risk of 2 anesthesia affects.  Why do I have to go through this, Forrest Park Medical Center in Dallas TX where the surgery is done is refusing my physicians request to do both on the same day and just charge me for the revision fee since I am under anesthesia and it is a lower risk to preform both at one time.  Why?  Because Forrest Park Medical Center in Dallas Texas wants the MONEY.  It should be my decision and not there's as to what is needed.  If my board certified surgeon agrees to perform this dual surgery to save cost and insure outcomes why should they refuse our request?  I say Forrest Park Medical Center CEO is Greedy, doesn't care that I am an overweight 57 yr old Wound Certified Nurse and knows how to make sure post op I follow instructions, nor does he care the risk of two surgery's is much greater than one with a person (myself) who already has 2 heart stents.  All they care about is GREED.  Shame on a medical center to tell a Doctor what he can't do.  Dr. Fox is looking out for me, has been there the entire time he knows how I am and is the best at his field.  Now I am miserable, sick and Forrest park wants my business two times.  They don't care about what is in my best interest just there's.  Does anyone know of a board certified center Dr. Fox can go to perform both at the same day, removal and gastric sleeve in Dallas.  I sure would appreciate it.

Karen Jones