Repair v. Revision?

I had an RNYGB 11/1995 and regained most of my weight. I'm currently being evaluated for "revision" but told I don't weigh quite enough for BCBS Federal to approve surgery. I'm scheduled for an Upper GI and I'm wondering what happens if is determined that I have a problem that needs correction. Would this not be a repair vs. revision? Do I still have to be 100 lbs overweight to be approved. (I'm 20 lbs shy of 100) How is this determined? I called BCBS and was told that the surgery would be covered based on medical necessity. Has anyone been faced with this problem before?

Hi, I'm getting ready to contact the ins. co. for a revision. Hope there is no problem. I think if it is a repair and you have other problems there should be no problem. My surgery was 2002. I've gained 23 pounds. My stoma has stretched. I have sleep apnea and herniated discs so hopefully they will cover.

Thanks for your reply. Please let me know what your insurance tells you. I'll say a prayer for you and hope all goes smoothly. My ins. company told me to find out what the "CPT codes" the surgeon will be billing under and she would be better able to tell me if the insurance will cover. Good Luck!!

The nurse said my BMI is 34. They usually won't approve unless 35. Since I now have sleep apnea they think I may get approved. In my eyes it is a defect that needs to be fixed. I don't know why they won't pay. I'll keep you posted.

Well, I got denied. I'm waiting for the letter. They based it only on my BMI not being high enough. So the appeal process begins. The Surgeon's office is helping all they can. I don't understand why they have to give it a name like revision. Can't they just say they are going in to fix the stoma? I'll keep you posted.

do they consider it a repair if they have to go in and redo the opening ? is that how it is submitted to the insurance? M

I was actually told at one point that my insurance, regardless of whether it is the first surgery or revision, will not cover unless my BMI is at least 40 or 100 lbs overweight - including co-morbids. (My Insurance is BCBS Federal) My guess is, the surgery would be initially denied and require that I go through the appeal process, with the help of my surgeon, to prove I need the surgery. I, too, have co-morbids.

I had my surgery 10-9-1998 I now have staple line dysfunction. I have had abdominoplasty(tummy tuck) so with the weight gain my tummy gets tighter each passing day. The dysfunction was confirmed by upper GI. The surgeon told me I have to have a BMI of 40 for my insurance company to cover the surgery. He sent me for a ct scan and wants to do and endoscopy and then we will discuss the revision\repair. I say Repair since the staple line is not intact he says revision. Tomato \Tomoto, you know how that is. The weight gain has caused problems with my feet for which I have had physical therapy for. My podiatrist says the second surgery will definatley help. I am not above using that to get approved. It will be atleast a month before we can even put in for approval. I will tell you that my Dr told me don't go home and gain weight just to be able to lose weight. Quarters in my pocket will work for me.LOL!