Second Surgery Exclusion Success?

Jumped through hoops for RNY to DS revision, then got told by husband's employer they have a second WLS exclusion. I know a lot of companies are adding this due to the high number of lapband revisions. i meet all of the requirements for original surgery, and I have complications that support medical need.

 

Has anyone successfully appealed this type of barrier? 

Modest Vixen

I am in AZ too can you please friend me?

 

What is your medical need to revise to DS vs. taking down your RNY only?  That is what they are going to look at.

It is not just lap band revisions that caused all this hoopla with ins co's and one WLS in a lifetime, it's ALL of them except DS.  Look at the boards, RNYers want revisions every bit as often as bandsters.  :o(

It used to be bands wanting revisions to RNY, now it is sleeves wanting revisions to DS.  RNY has always been a high revision type.

I can't really blame ins co's for their once in a lifetime WLS rules.  When people (not referring to you) flat out say that they are going to try a band or sleeve first and if that doesn't work then they will get what they really need, DS... how many WLSs should an ins co pay for?  I never ever see a self pay person making those comments but when ins is paying things are different.  Again, not directing this at you in the least.

Are you planning on Fang doing your RNY to DS?

You are right in the number of revisions, I was quoting the woman at United Healthcare. Dr. Fang will not be doing the revision, as he hasn't done nearly enough to do it yet but he did make the call on which type of revision I needed. He feels that due to the massive and quick gain (I was 200 this time last year, up to 271 with no dietary change at all). My hernia repair with mesh has caused a lot of scarring and a sudden onset of severe IBS. My scope showed stretched pouch and stoma. Fang said the results of "fixing the RNY" are not usually weight loss that I need so that is why he says the DS. 

 

I think you are going to be in for a major battle.  The once in a lifetime surgery, usually they will fix the existing surgery but weight loss, you are on your own.  :o(

Good, glad you are not having Fang do your revision.  Not that I don't think he is a good surgeon, he is.  I actually do like him for most surgery types.  But there is nobody in AZ who is honestly qualified to do RNY to DS.

I am a RNY first time surgery in 2000. I am being revised to a sleeve.  I just spoke with Dr. Juarez he will not do me a DS says its too dangerous of a surgery and I don't weigh enough.  I trust him I guess but my concern is if my pouch and stoma are small already what good is making it small permanently going to do me????  Modest Vixen do you know a Dr that will do a DS revision on someone of our size?

Please tell me who is doing your revision to ds? Juarez wont give me a DS,!

I was able to fight the second WLS exclusion.  I took 3.5 year of documentation from the band and all test done during that time.  Need was established before the first surgery but, I still had to re-met the need again.  It was proved when the band was removed that it did cause the medical problems I had.  Like stated, usually the insurance with pay to fix the problems with the first surgery only.  They covered band removal without issue base on the documented problems.

If you go to the DS boards they can steer you to people to hire that fight this and win.  See the above sticky too.