Denied Revision

I am so sick! I just got the letter in the mail. I just wish that I had prepared myself for the rejection. The lapband never worked for me. I never got restriction and when I finally did I was too tight and it caused severe acid reflux. I am now at the highest weight I have ever been, even before lapband. I guess I should be researching my butt off about appeals...I will just fight until I can't anymore. Thanks for listening. 

 

The wording on the denial

" There is no perioperative or late complication of previous bariatric surgery. There are no complications such  as staple-line failure, obstruction, stricture, non-absorption resulting in hypoglycemia or malnutrition, weight loss of 20% or more below ideal body weight."

oh it is so hard to get a rejection, and even when you know it is coming it doesn't make it easier.    so you have no complications from the band so the explant is not medically necessary, but you should look into you still qualifying for WLS...it doesn't sound like your insurance has a one only lifetime surgery with the wording of the denial.  you also should be looking at the wording in your subscriber agreement, know it well and follow all the rules, exclusions, covered services, appeals process, time frames....not following the rules....is an immediate way to be denied.   good luck to you

Their refusal sounds like they are talking about an RNY surgery not a band so I don't think they even know what they are talking about. Appeal appeal! There is no staple line in a band, no obstructions, no hypoglycemia or malnutrition and you weigh more not less so none of those things in the denial apply to the band! Good luck to you, I think you have a good chance!

Thanks for your help. I plan to fight and fight hard. I called my surgeons office today to see if they sent an appeal. I have contacted an outside agency that does appeals if they have not.

You should ask to see the letter that went out request approval and see the appeal before it goes out. There may be several errors which may effect approval.

Best,

Whitney

I was originally denied for almost the same reason.  There was no visible complication even though I kept getting stuck and vomiting.   I regained 20 of the 80 pounds I had lost.  They claimed I did not have a complication and that my bmi was too lo.  I filed my own external to ensure that my story was heard and presented my own medical  by researching pub med abstracts.  I won and have surgery on 8/20.  I'm happy to share my appeals language if you want to pm .

OMG!  My story mirrors yours almost exactly.  I got he Realize band in August 2010.  Did very well for the first 2 and 1/2 years.  Lost a total of 93.  However, in January 2013 I noticed that I wasn't feeling restriction so I went to my doc and she put in .4 ccs.  From that point on I still did not feel restriction although it showed on the fluroscope.  All I got was SEVERE heartburn and relux.  After trying to control it with OTC meds. I finally went back to my doc and she had to remove 2 ccs of fluid which really took away any restriction.  She recommended a revision to a sleeve.  My insurance denied, I appealed, and they just denied again.  I have now gained 30 pounds back of the 93.  Anyway you would be willing to share how you "filed own external".

Don't give up,  when I was denied I just started working on meeting the same requirements as if it were a new surgery. i didn't end up having to do it because when my advocate saw and sent in my supervised diets which the total out of my pocket was so great and i had been trying since 2009 they overturned their decision. i was denied and approved in a 4 day time frame.I didn't even know she had sent a request in for reconsideration. She told me to meet the requirements as if It were a new surgery.

 

Also i see there Is a attorney that OH has listed if need be.

I got denied for my LapBand & it took 1 year to get it approved. I had it 2 years and wanted to have the revision to RNY. Thought it was approved, made all the plans, did the diet, bought the plane tickets..etc and they denied it.. But with my patient advocates help, 45 days later I've had it done. They key is persistence & document, document, document! Good luck!