Denied by BCBS -they want a peer to peer review

I have a long story about the tortureous lap band that I need removed and revised to RNY. 

BCBS denied me today but is requiring a peer to peer review. They didn't tell the doctors office why I was denied but they wanted a peer to peer review. My doctor's advocate said this could be a good or bad thing. I haven't had a lot of test done just the barium swallow that showed how tight the band is. I've had terrible reflux, dysphasia, aspiration, and port pain. 

For those who have had a peer to peer review what was your experience?  

My friend and I were going through the same situation and she had a peer to peer and they still denied but then she requested an external review , a peer to peer is not the end of the line so don't give up even if it's denied . I've been converted from my awful band to rny 3 months now and had to battle it out with my bcbs but after 3 denials was approved . 

My advocate said they would keep going until we got approved. She said BCBS might want more information as in more test completed. I've only had the barium swallow which showed the band was too tight and has been since 2012.  I'll know tomorrow if the doctor wants to do the peer to peer or order more test first to be more prepared for the peer to peer.  And if he wants to post pone the peer to peer then she will ask for an appeal while additional test are being done. 

Welcome - if you add some more information, we may be able to give more suggestions.  How long have you had the band, etc.  Most people with bands are getting them removed and getting WLS by the 5 year mark. 

Is there any reason why insurance thinks you would not be successful with the RNY?

Hi Sharon!! Thanks for responding!!!

Ive had the band since December 20, 2011. I've been throwing up since then and it got worst. The reflux, dysphasia, and aspiration has gone on for years. I've dealt with it but I've gotten tired of throwing up and feeling bad. My surgeon and OBGYN but said to get rid of the band. In addition to all of this my lowest weight was 156-158. I started in the 190s.  As a self pay lap and patient. I'm back where I started in terms of weight and I feel terrible most days. My port hurts, always feels like trapped gas around it. 

The insurance didn't give a reason why they denied according to the bariatric coordinator/advocate. I'll talk her tomorrow and get more info. 

Any suggestions?

Also, check the language of your health insurance policy - I was surprised to see that mine covered complications from elective surgery, even when they didn't cover the elective procedure to begin with.  

Some people get their lapbands out and WLS at the same time, for others the lapband has caused so much scar tissue, that they get their bands out and have to wait 6 months before getting the WLS(from what people are saying in my Support Group Meetings).

https://www.dssurgery.com/resources/videos/

I found this doctor that specializes in revisions, I do not know him, but someone on the Revisions Forum said he was good.  Anyway, he has a great video of a band removal surgery (if you can tolerate actual videos) that show what has to be done for a band revision.

I hope that you get a insurance person who is having a good day!!

My doctor wants to do it in one surgery.  I will review our policy.    Thanks for the tips. 

As a rough, general rule, they have an easier time going from band to RNY in one surgery than band to VSG. They usually like to wait several months for the stomach to heal if someone insists on the sleeve. The awful band creates a lot of damage that RNY doesn't go near.

Good luck.

First, good luck!  My neighbor had to undergo the peer to peer review and he was approved.

Thank you for this ray of hope.