Insurance denial/crap- band to RNY
Received word from MD's office that Anthem BCBS denied my request for RNY after having crap-band for 8 years. I actually had great success for the first 5 years then started experiencing all the reflux, innability to tolerate restriction, leaky tubing, lost restriction, etc. I have gained back 100 lbs of the 125 lbs that I lost in the first two years. Anthem feels it is not medically necessary and I have not participated in a recent physician supervised weight loss program. WTF?? I have been on diets since I was 9 years old both MD supervised and not. I have only shown true weight loss when I had a working lap-band and once I lost the ability to use that tool, I gained back the weight. What else could they possibly want? I wrote a letter of appeal, had three more MD's write letters of support and went to HR to see if they could intervene. My surgeon also sent an email to human resources (It helps to work for the hospital that runs the bariatric surgery program). With a BMI of 60.1, sleep apnea, osteoarthristis, hypertension, chronic pain, and chronic vascular disease, I can't imagine how they could say this is not medically necessary. All the additional info was sent to Anthem today and a "peer to peer" phone call is scheduled for next week with my surgeon and Anthem medical director. Wish me luck!!!
Did you do a medically supervised diet for the band? Maybe that could be counted. Also if it were me I'd start working with my doc right away getting a supervised diet going so that you would have that to use in your appeal too. It sucks but I know lots of folks *****vise have to start from scratch with all the requiremnts, the diet being just one of them. Good luck to you!!
they may be looking for a mechanical failure. reflux and inability to tolerate a fill, you need a barium swallow and and endo. be very careful with Barretts esophagus if you have a bmi of 60 you don't need co morbs to qualify, for WLS. Having hte band for 8 years (restrictive) and revising to RNY (restrictive) you may want to consider adding malabsorption (DS) for your revision. I had the lap band longer than you. I went form a bmi of 61 to 19, in about 15 months. the first 6 yrs were a easy, easy, no problems, the next year not so great, the last 2 years i got progressively worse to a point i thought i would lose my mind and my complete sense of normalcy was gone. the lap band had destroyed my esophogus, permanently, another restrictive procedure was out of the question for me (VSG, plication, RNY) another thing you have to think about is you are accustomed to being "tight" that feeling is permanently gone, has anyone explained that to you, how you can eat around VSG and RNY easily post lap band, due to the loss of how you interpret restriction. I urge you to speak to a surgeon who does all WLS (lap band, VSG, RNY and DS) any a surgeon who does all surgeries and deals with revision patients will understand the special requirments a lap bander has. I have never have had restrictiion since I lost my band, it is permanently gone...or I no longer know what feels like. Do a lot of research, only you know what is best for you. I wish you a wonderful journey and a healthier life after your revision.....
Lilibear, I am very sorry that you are dealing with this! I also got initially denied to revise from the "realize" band to RNY because I had "exhausted my one bariatric surgery a lifetime" limit. I never lost weight on the band and the dratted thing is near full and I still feel no restriction and I can tolerate all foods. Its been a long process. I appealed the denial at the beginning of October and was medically cleared and had the denial overturned. This was after giving up in August and then doing a "what the hell" and asking everyone to write letters of support and as to why they supported my revision surgery. Between my medical records, my doctor,surgeon and the psych, and my boss and various family members, I got it done. So do what you need to do and fight it all the way to the top!!!
Your situation sounds very similar to mines but the only difference is that I was revising to the DS. I would listen to airbender and really do your research on ALL of the surgeries before settling with RNY. Since this is the second time doing the WLS you need to pick the best surgery so you wont have to do this again. With such a high BMI you may want to consider the DS as an option. I was also told its is not medically necessary and I needed to prove I was on a supervised program. I appeal and won my appeal with BCBS of IL. I wish you nothing but luck.
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