Revision from a Gastric Sleeve to a RNY due to complications.
I had a self pay gastric sleeve approximately 12 years ago in Mexico. I lost approx 100 lbs and I have kept it off. In the last couple of years I started throwing up a good bit. After many test my American physician found that I had a large para esophageal hernia that was pushing a 1/3 of my stomach into my chest cavity. I had the hernia and my diaphragm needed repair. My doctor said my sleeve looked good. He said it was larger than what they make them today, but looked about the size the doctors did the 12 years ago. After the hernia surgery, I continued throwing up. My surgeon now says that the only way he can correct my problem is to convert me to an RNY. My BCBS is not wanting to cover. Even though I was not insured with them 12 years ago they said I didn't go through an insurance company to get approval for the original sleeve. They are also pending my follow up visits from the hernia repair and requesting medical records. How can they do that? Is that legal? Also, in December I will be eligible for Medicare. I was told that traditional Medicare would cover my revision, but if I went with a Medicare Advantage plan they may not. The Medicare Advantage Plan would be through my husband's retirement benefits. Has anyone had this problem before? If so, any suggestions on how I can get BCBS to cover this. Any recommendations on which Medicare plan I should consider?
On July 20, 2019 at 10:44 PM Pacific Time, Wolvesfan1 wrote:
I had a self pay gastric sleeve approximately 12 years ago in Mexico. I lost approx 100 lbs and I have kept it off. In the last couple of years I started throwing up a good bit. After many test my American physician found that I had a large para esophageal hernia that was pushing a 1/3 of my stomach into my chest cavity. I had the hernia and my diaphragm needed repair. My doctor said my sleeve looked good. He said it was larger than what they make them today, but looked about the size the doctors did the 12 years ago. After the hernia surgery, I continued throwing up. My surgeon now says that the only way he can correct my problem is to convert me to an RNY. My BCBS is not wanting to cover. Even though I was not insured with them 12 years ago they said I didn't go through an insurance company to get approval for the original sleeve. They are also pending my follow up visits from the hernia repair and requesting medical records. How can they do that? Is that legal? Also, in December I will be eligible for Medicare. I was told that traditional Medicare would cover my revision, but if I went with a Medicare Advantage plan they may not. The Medicare Advantage Plan would be through my husband's retirement benefits. Has anyone had this problem before? If so, any suggestions on how I can get BCBS to cover this. Any recommendations on which Medicare plan I should consider?
I think it would be against the law to request your medical records , due to OSHA regulations. I also think it would be considered a pre existing condition so they legally have to cover it.
Dont know for sure but that is what Oi think.
You might consult with lindstrom, who is a group of attorneys who work getting insurance to cover when they should,but don?t want you to know they have to.
I have not heard of Lindstrom. Where are they located and how can I reach out to them? Do you have any knowledge of how Medicare would handle? If my insurance is not going to pay, I'm going to have to wait until my Medicare becomes active in December. It's a daily struggle, but I can't afford to pay more out of pocket. As it is now, if they take back all the money they have paid for the hernia repair, test, etc. I'm probably over $200,000 in debt and that's more than I can afford before getting my problem resolved.
I have not heard of Lindstrom. Where are they located and how can I reach out to them? Do you have any knowledge of how Medicare would handle? If my insurance is not going to pay, I'm going to have to wait until my Medicare becomes active in December. It's a daily struggle, but I can't afford to pay more out of pocket. As it is now, if they take back all the money they have paid for the hernia repair, test, etc. I'm probably over $200,000 in debt and that's more than I can afford before getting my problem resolved.
I don't know what Medicare would do. Lindstrom is in Los Angeles, ca. You can google them of r a phone number. They will give you an idea of if they think they can help you by a free phone call. Good luck.
Are you stating Traditional Medicare would not cover the conversion to an RNY because I had the original weight loss surgery (gastric sleeve) in Mexico? Also, it sounds like you have a Medicare Advantage plan if your coverage is through UHC, correct? Sorry, but I'm just a bit confused.
Thank you for your response.
