Need Advice-Insurance Denial

I had the sleeve done in Dec-2012, lost all my weight, kept it off and life was great, up until 8 months ago. I woke up in the middle of the night feeling like I was drowning!!! My lungs were filled with bile, my gastroenterologist brought my in immediately for an endoscopy. He found a very small hiatal hernia, but the muscle in the esophagus that keeps food and liquids down, no longer works. He referred me to a bariatric surgeon to have a revision from sleeve to bypass, he said my risk of stomach and esophageal cancer are very high, and the risk of aspirating is also of great concern. I saw a bariatric surgeon, he did an upper GI, and also an endoscopy, and he put in for a stat revision, for the same concerns as my gastro Dr. Needless to say, my insurance company UHC denied the bariatric surgeon, claiming he is not a UHC approved bariatric surgeon, but they did an over ride and sent me to the Mayo clinic. I seen two approved bariatric surgeons there, they both agreed with the previous doctors, and scheduled surgery. The day before the surgery, the insurance denied the procedure. A week later, a peer to peer was done (both surgeons at Mayo, with UHC doctors), and it was still denied. It was denied because I am not morbidly obese!!! They would not look past my BMI, the fact that I could die from cancer or aspiration was not of any concern of there's. The Mayo clinic is filing an appeal, but they also want me to file a separate appeal. I'm scared to death of aspirating in my sleep. I sleep sitting up because when I lie down I get horrible, horrible reflux. Does anyone know how long the appeal process usually take? I am considering going to Mexico for the surgery if something doesn't happen soon. I only sleep a couple hours a night, I've been out of work due to having knee replacement surgery, but I don't know how I'll function when I need to return to work. The lack of sleep, and the stress are taking a toll on me. My anxiety has been so high, I haven't been out of the house (except to walk my dogs) in two weeks. I don't know what else to do.

Sorry, I don't know anything about appeals. I have had GERD for most of my adult life. Has your MD put you on a PPI?  Also, stop consuming anything with caffeine or peppermint, which can irritate your esophageal sphincter and cause GERD to be worse.  Chocolate also has caffeine.  It is good that you're sleeping elevated, also don't eat 2 hrs before bedtime. I hope you can get this appealed.

I've been taking PPIs for several months and they don't help. And it's the sphincter muscle that no longer works. The Mayo clinic is conducting trials in which they use a metal hoop around the muscle forcing it to work, but they said my is so severe, it probably wouldn't do anything for me. I don't drink any caffeinated beverages, and no carbonation. I also don't eat or drink anything at least three hours before bed, so the stomach bile ends up in my lungs, and/or throat, what a horrid taste!!! They say my refulx is so bad, they would put me in the 90 percentile of getting cancer from the erosion. Every single doctor said the same thing. I actually got my insurance denial letter today, and they denied my claim stating there is no evidence showing a revision would help with reflux, and all the doctors said this is the only thing that would stop the reflux. Ughhhhh

Wow, I am so sorry. I saw a post here or on FB, where someone had the nissen fundoplication with the sleeve (part of DS) for severe reflux. You may want to research that. I wsh you luck with your journey.

Donna

I can't have the gastric plication with the sleeve, and that wouldn't stop what's going on, I need the by pass. All they do with the plication is staple your stomach in half, that would make this reflux 100 times worse. Thanks for your thoughts though :-)

Gastric plication is a completely different surgery than a fundoplication. Whether or not you can have a fundoplication with a Sleeve *probably* depends on just how big your Sleeve is. You're correct that a plication would only make things worse, but in a fundoplication the actually wrap part of the stomach around the esophageal sphincter to tighten it.

Fight it and get a lawyer if you have to. 

I had to fight Cigna for almost 9 months until they finally agreed to the revision.  They denied me 3 times, denied the peer to peer, and it wasn't until it went to the national appeals department did they finally agree my issues were severe and agreed to remove the lap band and revise me to the bypass. 

There is a lawyer who specializes in WLS denials ask on the main board or search it I forget who the law firm is.

Good luck.

Go to www.bariatricfacts.org and contact a woman named Diana Cox. She's both a lawyer and a biochemist, and she's helped a LOT of people overturn denials, pro bono. Usually she works on overturning denials of the DS, but I've no doubt she could help with this as well.

I suspect part of the problem lies in how your surgeons have been submitting. Instead of approaching this as a revision of a prior WLS, approach it as a surgery for fixing a definite medical problem. See if they can get you approved for a Nissan Fundoplication. If they approve you for that, and when your surgeon gets in there it's not physically possible to do the Nissan...well, you get my drift. (*grin*)

Nissen fundoplication IS SURGERY specifically to treat your issue, which is an incompetent lower esophageal sphincter. The wrap creates a much tighter seal, inhibiting the reflux backup

I have appealed medical decisions for my wife not weigh loss  but ergent . UHC and care first both have 30 days to give a decision  for eachnleve. I tried once to request a case manager and with working with case management had some luck getting help for my  wife. It's worth a try you can also appeal to your state insurance commissioner.