Surgeon Talking to the Medical Director
Quick story:
I got the lap band in Dec. 2009. I never lost much weight with it. The most I was ever down was 40 pounds and 20 of those were lost the first trimester of my pregnancy. During my pregnancy I started having some terrible acid reflux, waking up choking on it and coming out of my nose. My doctor assumed the band has slipped a little, but could not confirm it with the barium and x-ray because of the pregnancy. (My OB did not have me unfill my band and just kept a close watch on the growth of the baby.)He just drained my band and told me to come back after I was done nursing the baby. Everything was great for a while!
Fast forward about six months: With an empty band, I would randomly have stuck episodes and throw up. Sometimes I could eat anything and everything, and others, I would throw up fluids. Since I was able to eat sometimes, I just dismissed it. I had a lot going on during the first year of my daughter's life (major surgery at 6 months) and I was still nursing. I also thought that it may not be band related since it started happening out of the blue with and empty band. Finally in December I stopped nursing when my daughter turned 1 year old. The vomiting and pain had gotten worse over the past few months so I made and appointment to see the doctor and saw him in January.
When I weighed in at my appointment, I had gained all but 13 pounds back. The doctor immediately determined my band had slipped just under the x-ray without the barium. When I did drink the barium, nothing moved at all. He was able to push around and get an additional 2cc out of my band and got things barely flowing. He said that the band has to come out and suggested that I consider a revision since the band didn't work for me. We talked about the RNY and DS and I ultimately decided on the DS for various reasons.
Today, the insurance coordinator from his office called and said that my insurance approved the band removal but denied the DS. She asked some additional information from me about the original surgeon who preformed my surgery (I moved to a different state after surgery) and said that the doctor was going to talk to the medical director and she would call me back when she hears something. So does anyone know what that means? Is the medical director someone at the insurance company who may be able to overturn the denial, or what? Has anyone else been in this situation?
Sorry so long!
Lots of insurance do not cover the DS at all. Does yours cover the sleeve. Even though you will hear hear the DS is best, there are many Doctors and insurance companies that don't agree. Mine just started covering the sleeve this past year and no way will it cover the DS. There are no centers that do the DS in my area. There are only two centers in MI that I know of that do it. Did they agree to cover the RNY for you? Just asking questions.
When I was fighting the insurance co to get approved for the sleeve. I did a phone peer to peer with the Supervisor of Customer relations and Supervisor of referrals and the had a meeting with head medical reviewer to determine that I would be approved once I met the same standards to get WLS. This might be the same position you are talking about and if it is , yes they can. Hopefully it is.
BAND REMOVED 9-4-12-fought insurance to get sleeve and won! Sleeved 1/22/13! Five years out and trying to get that last 15 pounds back off.
Go for the DS!!!!! As an RNY revision to the DS.
If you have to appeal your insurance, do it!!!! I fought for my revision & won!!!! 2 appeals, and a telephone hearing. FIGHT for what YOU WANT!!!!!
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
If they cover the DS and your surgeon is experienced with it and he thinks it best, I'd go for it. Fight your insurance for your revision. For me, I wouldn't get the RNY knowing what I know now. Just was wondering if the the insurance was saying yes to it.
As far as the sleeve, I will be four weeks out Tuesday and am already to my band's lowest. The sleeve is so better than the band.
Let us know how it turns out!
BAND REMOVED 9-4-12-fought insurance to get sleeve and won! Sleeved 1/22/13! Five years out and trying to get that last 15 pounds back off.
I feel for you. I had my band for over 5 years.....what an ordeal. I wasn't preggars with the band BUT I had the same problems as you. one day I could swallow whatever..next day I couldn't get my liquids down. I would have to say do your research....I got y revision from band to DS because I felt it was the best for me. Keep us posted. If you want the DS....fight for the DS...APPEAL!
