Question:
I need a revision to my gastric bypass and Blue Cross won't cover it!

I had gastric bypass done Dec. 7, 2001 and only lost 64 lbs. (of the 160 I was shooting for) and have now gained back 14 (I started out at 309, and am now holding around 259). I had an UGI done and it revealed that my pouch has indeed stretched, so my doc wants to go back in and make the pouch smaller again with a partial gastrectomy, but Capital Blue Cross (here in PA) is denying it, saying it's not medically necessary and they won't pay for any WLS revisions! What can I do? I can't afford to pay cash for this. I'm working on a letter to fight it, but don't know if that will work. It's very depressing to have come this far and know that one final surgery will correct this minor glitch and get me on my way again, and I can't get it done! Can anyone help me? Please e-mail me (Lori) at [email protected] - Thanks!    — tropicswriter (posted on March 30, 2003)

March 30, 2003
Hi Lori. I'm sorry you're having these problems but your question just makes me want to ask more questions. How did your pouch stretch? Did the surgeon leave it too large to begin with? If not, was it your eating habits that stretched it? If so, have you taken steps to correct the situation? (Nutritional Counseling, Weight Watchers or other weight loss group, etc.) If the fault lies with the original surgery, you may have grounds to overturn the decision denying you coverage of the procedure. However, if the problem was bad eating habits that caused the stretching, Capital Blue Cross will probably continue to deny you based on the fact that they covered the initial procedure (I am assuming they were your insurance company at the time of surgery). They did not deny you the bypass surgery at that time because you had proof from your physician that it was a medically necessary procedure. It seems to me that you need to try and prove that this is medically necessary again. That seems to me to be the only way you'll get your insurance company to change their decision. Sorry to be the devil's advocate here -- insurance companies aren't easy to deal with under the best circumstances. Good luck.
   — Pam S.