Denied but hopeful ??

Well Blue Cross Blue Shield has denied my request for revision due to reasons of not seeing enough medical complications from my band which is ridiculous because my EGD test results that they received showed severe severe ulceration polyps that had to be biopsied and a narrowing of my esophagus . The doctors office has a call into the nurse that made the ultimate decision at Blue Cross and she said she is determined to find out what reason we cannot use that clinical findings. Also talked to my union rep at the insurance company and she said that if that is not good enough for them she will go ahead and file it and see what happens. She also stated that they only use Blue Cross Blue Shield official insurance bariatric coverage as a guideline

Not hopeful. It's a no. The medical examiner feels that reflux, Port pain, esophagitis, ulcers, polyps , strictured esophagus, gerd is not proof that my actual band is the problem. Can't get a fill or my problems wil get worse so I'm stuck with a 50 lb weight gain and can't really diet Bc nothing goes down and stays down except sliders . I wonder why it would feel like to be able to enjoy an apple with some broccoli and chicken breast . 

Feeling like I'll never know. 

My husband is a union employee and as in $3.00 per hour towards our insurance benefits. He puts in hours  per week . Yes. 7 days a week... 12 hours per day . And yet we can't get a needed surgery Bc a medical examiner doesn't think it's needed . 

I've heard good thing about Lindstrom Obesity Advocates-- maybe be worth using them to fight this denial

Fight it with appeals and peers to peers and if it comes down to it get a lawyer. 

I had to fight Cigna for almost a year until they finally gave in and approved my band to bypass revision.  And it was a dam good thing they did or **** would have hit the fan.  When I had my surgery done it took my doctor over an hour to chisel my band out as it was encased in scar tissue along with the tubing and port.  The entire thing was very inflamed and the reason why I was having so much pain.  This was nothing that could be on a CT or ultrasound. 

My surgeon put in the OR notes that had the band not been removed when it was then the patient would have had to have emergency surgery due to the condition of the band that was found.

Ahh thank you for the hope ... May I ask what your reasons were for removal ? They are saying my issues can't be proven that they are caused by only my band 

My doctor got aggressive when it when to the Cigna national appeals. 

He stated his patient was having esophagus spasms, had excessive tightness with no fill and was unable eat properly, and then there was the unexplained pain.  I would get pain where my port was and it would radiate to my breastbone.  There were times it was hard to take a deep breath.   I dealt with that crap for 3 years and had the band for 11.  I did fairly well with the band at first, but then the issues started to set in.

You have a lot more issues than me so I am surprised that BCBS denied you.  Fight them and don't give up.  Get aggressive if you have to.

I am not sure WHAT schooling a 'Medical Examiner' has but I do know, in some cities, a RN or a EMS person can 'run' for the position. That means the person hired by your insurance co. could not even have a CLUE as to your banding or the WLS and their side effects. DO NOT SIT and do nothing...or you will end up getting nothing. I better stop there.

Go see a Gastroenterology MD and have him do an Endoscopy and that will see EXACTLY what is up with your band, the pouch, and any unknown, hidden things he might find. HIS report, sent to your WLS surgeon and might get you a revision.

Also, what co-morbidities do you have diagnosed? USE those, too.

I have submitted 70 pages of medical records as well as my egd results that showed esophagitis , gastritis , ulceration, strictured esophagus and polyps, as well as an appeal letter.... That all went through on Friday so maybe the elected medical examiner will change their mind. I'm quite sure by now they have realized I'm not just going to give up.

annoying and persistent is often what does it! I don't know IF the 'medical examiner' in the city where the records are looked at IS elected, but I DO know that often the people who are making the decisions at BIG insurance companies are often LAY PERSONS who have no business looking at nor making denials. I had it happen to me back in 1995 when these surgeries were new. I was persistent like you and finally made friends with the person who was in the decisional dept and she was VERY HEAVY and just denied others because she was angry at the world. Once I told her how she could qualify for the surgery and helped her find a Bariatric surgeon close to her home, my surgery got approved. We do what it takes.

I hope you WIN!

Don't give up hope, I also was originally denied by Blue Shield based on the fact that I didn't exhibit any of the qualifying attributes outline.  I was given 120 days to appeal.  Amazingly as I was working on gathering my info to do just that I got a call from my surgeons office to schedule my appointment.  Strangest thing!!  Apparently the surgeons office just resubmitted the same package and it was later approved.  I'm not asking too many questions....  I wish you luck,but more than that stay focused and don't give up!!!  Good luck.