Revision--DENIED!! What do I do now??

Ok, so its not like I'm surprised.  I knew there was a high likelihood that I would initially be denied for revision.  The plan was to at least get the band removed (the Dr. was going to do the revision in 2 separate procedures to allow the stomach to heal) and try again with under a different policy next year (that way they wouldn't have to know I ever had bariatric surgery).  My current insurance company will not even approve a removal because I don't have any complications from the band and they don't feel I've tried hard enough to lose the weight.  (I used to feel that way too...but its been 3 yrs, and I still have diabetes and PCOS to contend with and its hard as hell to lose weight with these 2 particular conditions!!!).  I think I have a right to have the band removed if I no longer want it inside of me! Although I despise being denied, I'm not devastated or anything, but I do intend to give the insurance company a hard time until they at least agree to pay for the band removal.  How do I do that?

I would fight it! I never had to fight it...there has got to be a forum here that will help you. I had my band taken out on 1/24/13....thank The Lord......I had alot of vomiting...no slippage or damage....I was also getting Reflux...think of anything that is causing you any discomfort or problems. I didn't have to fight....Dr. heard what I had to say and he told me it was coming out. I also got revised to the DS all at the same time. Good luck to you......I know I have seen peeps on here fight and win appeals;)

Have you posted on the main board, or the insurance board?

http://www.obesityhelp.com/forums/insurance/

 

I had to fight to get a revision, nearly 3 years.   IT SUCKED, but, I won!!!!!!!!!!

How does the duodenal switch compare to the RnY?  I was flip flopping between the two surgeries, but only one surgeon in my area does them.  Since I have to wait, I might decide to explore this option more.

The DS has the same stomach as the Sleeve, plus an intestinal bypass similar to, but more effective than, that of the RNY. The DS, in my opinion, gives a more normal quality of life---no dumping, no getting food stuck, you can take NSAIDs and drink with meals, rarely do DSers have food intolerances or reactive hypoglycemia (both pretty common with the RNY), and, best of all, the DS has the very BEST long-term, maintained weight-loss stats. It also has the best stats for resolving or preventing co-morbs like diabetes and high cholesterol.

We have a lot of folks around here who started out with the RNY and got revised to the DS---but only one that went the other way, and she'll tell you herself she had zero follow-up for her DS.

Keep appealing it, usually you can do it several times. Get your doc on board, ask for a peer to peer meeting with your doc and the insurance people. Like the others said bring up any issue the band might be causing like GERD or swallowing issues. Don't give up yet!

You can get a lot of information on the http://www.obesityhelp.com/group/failed_lap_bands/  group.

I fought to get mine out.  I had to show a history of issue.  I went in at one year out and they unfilled it to do a scope as the upper GI showed I was wide open and couldn't swallow spit at times.  The scope showed Esophageal issues requiring a total unfill for 6  weeks.  I never could get it filled back right.  I also had it totally unfilled at 2 years for 2 months and slowly tried to refill.  For the last year I went in at least once a month for fills and unfills.  My insurance had just approved me for 28 fills/unfills for the year at $225 each.  This was totally ridicules to me and an admission I was having fill issues.  I was seeing them for random tightening and loosening for that last year. I was having to sit up at night due to the reflux and they had put me on two PPI's a day the 18 months earlier.   I used all this documentation to fight them.  They had all my weights and the link to my gains. 

Not only did this get my band out but, it got me a revision to a sleeve with my insurance with a once in a lifetime WLS policy.  I had a verbal peer to peer with the Customer Supervisor and the Referral Supervisor who meet with the Head of medical review.

 

My surgeon's office, particularly the insurance coordinator is doing very little to help.  I asked for a peer-to-peer between the Dr. and the insurance company and all she did was try to assure me that that won't work because the insurance company believes I have been non-compliant.  I despise nay-sayers!  If I can't get them on board, I am going to another surgeon!  I think insurance companies use the non-compliant excuse to make people feel guilty about failing to lose weight with the band.  That's not going to work for me.  I have a two-fold plan.  One, I am going to appeal until I can't appeal any more, so I am going to see what advice I can get from the insurance forum.  Two, I am going to work the hell out of this band for 6 more months (or until they approve me, whichever happens first) and document everything (diet, exercise, fills, complications, and weight) myself (on a blog, so it will be time-stamped and they can't say I just made it up).  If this appeal does not work out for me, I am going to resubmit everything again in August/September.  At that point the non-compliant argument will be a moot point.  I also intend to keep seeing the psych and using the nutritionist as need be.  Hopefully I can at least get the insurance company to reconsider the removal.  If I can get that approved, then I will keep the removal in my back-pocket ****il the end of the year) so if showing compliance doesn't work, I can go back to my original plan of getting the band removed this year, and reapplying for bariatric surgery next year under a different policy.

My surgeons insurance person was a nay-sayer too.  That is why I called and talked to the supervisions myself.  She did back me up though when they called her to confirm all my visits and issues.  I sounds like you have a good plan.  And be very vocal at fill visits of any issues and come tight out and tell them you want it documented.  I found some of the stuff wasn't being put into the records.  My PA made sure she noted for me all I had had happen in the past.

Go Get Em

Ok I do get the insurance fraud memo. I am not going to lie, but I am also not going to give more information than asked for . I think my full disclosure approach has been used against me so I'm only going to give as much information as asked for. If asked if I had a previous bariatric surgery I will admit I had the band, if asked why I don't have it any more I will say it was lap band failure.