Lap Band Revsion insurance approval/appeal

Hi Everyone,

I had my lap band placed 12 years ago. I've been trying to get it removed for the last five for various reasons such as frequent vomiting, GERD etc. My insurance DOES have a once in a lifetime clause HOWEVER it will revise if medically necessary.

Until now, I have never appealed the denials. I am currently fed up and can't go on much long. I never gained all of my weight back but my BMI is 37 with these co morbidities:

Morbid obesity

Gastroesophageal reflux disease

Multiple joint pain

Depressive disorder

Benign essential hypertension

Anybody have a similar experience. I could use some advice with the appeal process too because I'm not giving up this time. I have BC/Bs Personal Choice (PA)

Several people on here had good experiences with Lindstrom.
https://wlsappeals.com/


This might give you a start if you are trying to do it on your own

https://vsgappeal.blogspot.com/2009/06/appeal-letter.html

I would work with your surgeon's office and getting them to make the case that the revision is medically necessary. They really need to know all of the side effects and complications you're experiencing ****pt a list on my phone since it was easy to forget about all the little things I have just learned to live with over the years that were not normal). Make sure they understand how miserable you are, how it's affecting your life, emphasize how your current tool isn't working as designed and that you need a solution to the issues and complications you are experiencing. They should be your advocate and help with your insurance company.

I had the same insurance requirement and I had similar issues with frequent stuck, vomiting and GERD. Year after year I would go in and they would run tests, confirm I didn't have a slip or any mechanical issues so I figured there was no chance to revise. I finally gave up and had just had them empty my band, even though that did not resolve my issues. I went back after 3 years since I was still having issues stuck issues daily and really pushed for them to help me. I made it clear I wasn't going anywhere and that I wasn't going to just deal with these issues for the rest of my life. They helped me pursue a revision and when my insurance initially denied it they did a "peer to peer" with my insurance company and it got approved.

Good Luck!

This is me EXACTLY!!!!!!! I have gone year after year to get denied. I am NOT giving up this time and taking it as far as I have to.

Thank you for giving me hope!

I had a revision from Lap Band to VSG with Blue Cross. Before approval, I had the following assays:

Esophageal manometry

Barium contrast study

EGD (endoscopy)

I had a diagnosis of GERD caused my reduced motility of my esophageal sphincter due to damage caused by my band... Well, caused by me overeating for 14 years so that the food pushed up against my lower esophagus.

My surgeon submitted the study results and a recommendation and I got approved for surgery. My appeal came when I went to get my revision and they said no because my first WLS was a "failure". My appeal included study evidence showing that my weight loss was average for lap band, 30% excess body weight, and that I had to get it removed for medical reasons. Eventually I was approved.

My surgeon made me weight a minimum of 3 months after band removal to get a sleeve surgery. I wound up waiting 6 (May-Nov) and used evidence that I didn't gain over that period as justification to support my eventually surgery approval. (my earlier approval had expired during the intervening months)

It's a long slog. They make you jump over many obstacles.