Aetna POS II Revision Before Two Years

Hi all,

I got the sleeve August 2017. I'm looking to get revision to either bypass or DS. Ideally, I'd like to knock it out quickly. Given I can get everything taken care of for pre-op diet, etc. I'm trying to understand if I could get it before the 2 year mark? The policy is a bit confusing:

Conversion to a sleeve gastrectomy, RYGB or BPD/DS is considered medically necessary for members who have not had adequate success (defined as loss of more than 50 % of excess body weight) 2 years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure;

Does this mean I need to wait till after the two year mark to submit to make sure I don't get debite for that reason? Has anyone submitted to Aetna POS II prior to the two year mark and been approved for coverage?

Any help would be much appreciated!

From what I am reading it appears you have to wait the 2 years and it would have to be medically necessary in order to qualify for a revision. You would also of had to of been compliant with the prescribed nutrition and exercise program following the original procedure.

What is wrong with your sleeve? Why do you want a revision?

Doctor went through the additional items with me and believes it to be medically necessary.

Do you have Aetna? Would love to understand your background to further understand yooy interpretation of the bulletin. Thanks!

I do not have Aetna I have Cigna. I was just going by what you wrote.

Conversion to a sleeve gastrectomy, RYGB or BPD/DS is considered medically necessary for members who have not had adequate success (defined as loss of more than 50 % of excess body weight) 2 years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure;

I don't understand what you mean by additional items. When it comes to a revision there are either complications or non-compliance.

I had a revision from band to bypass due to medical necessary. Even with an empty band it was tight and the acid reflux was horrible. I was eating tums like tic tac to get any relief. I tried to eat dense protein, but no matter how well I chewed or what type of meat it was I would vomit. When the revision was done it was found that the band was encased in scar tissue and that is what was causing my band to be tight. Had I not had the band out it would have eroded into my stomach.

So I will ask again what reason do you need a revision? What did the doctor find in your sleeve that you need to have a revision?