BCBSIL band revision insurance coverage success?

Hello -

I'm going in for an endoscopy on Thursday to determine if I have a band erosion or slippage.  I've been experiencing bad acid reflux, increasing tightness and last Thursday, found myself in the ER after vomiting blood.

I had an emergency unfill and fluoroscopy over the weekend (I thought I had 1cc in my band but it turned out to be 3!) and am feeling somewhat better, but am still fighting with acid reflux.

My surgeon thinks the likely outcome will be that I've experienced an erosion or slippage.  I've had the Realize band for six years without complication, lost 80 lbs at my best, but have been maintaining a 60lb loss for the last several years.  My BMI is still just over 29.

Should I need to have the band removed and reconstructive surgery done on my esophagus and/or stomach, I'm thinking the gastric sleeve may be the best way to help me keep the weight off that I fought so hard to lose.

I'm reading mixed reviews about the BCBSIL approval process.  I have their PPO+ plan, and if my band has failed from erosion or slippage, I believe I qualify at the most basic level.  However, my BMI is considered low, and my first surgery was self pay.   

BCBSIL will end up paying the same amount of money for esophageal and/or stomach surgery to repair the erosion and any malformation or scarring in my upper GI, but I know the insurance world operates by codes and scripts so this justification may be lost on them. 

Any advice you have for navigating the waters of dealing with insurance companies would be much appreciated!

xo,

-e

The surgeon should know how to word and bill it to get it covered as long as you aren't wanting him to out right lie about what is being done. It's quite possible that if it is an erosion he will have to remove at least some of the stomach anyway because of the damage. At this point the most important thing is to get that band out ASAP before it causes anymore damage. I had to pay for my removal because my insurane doesn't cover bariatrics OR complications from bariatric surgery so they are covered no matter what I had to do to get rid of the pain mine caused me. Good luck!

Fortunately, my endoscopy revealed two small ulcers that, had I not started medicating with Prilosec immediately after that first bleeding episode last week, would have likely become erosions.  I caught it just in time.  I'll have to take prilosec twice daily for the next 3 months and come back in for another endoscopy to make sure I'm all healed up.  Though ulcers are generally caused by bacteria, these were likely made worse by stress.  I have some work to do on that front, so that this does not become a chronic issue (read: less stressful job).

It's pretty amazing that six years after banding, I've had no problems with it other than temperamental tightness at the most inconvenient times.  No slips, erosions, port problems, reflux, etc.  I've been a compliant bandster, but I also have my surgeon Peter Billing to thank for doing such an amazing job.  

For now, conversion surgery is off the table.  It's not worth the risk unless I continue to have issues with ulcers that threaten to become erosions.

*happy dance*