Question:
How do I prove that I have been

I am in need of a revision from a SRVG to an RNY. I meet criteria A, C, & D down to the dot. I have some (3 or 4 notes in chart) medical documentation for B and 1 years worth of weight watchers weigh in cards. Does anybody know what it takes to convince BCBS of TX of substantial compliance? If I don't prove substantial compliance, does that mean I'm non-compliant? I am about 18 months post op. This is BCBS of TX revision criteria: Repeat of a Covered Bariatric Surgery Repeat of a covered bariatric surgery may be considered medically necessary only when ALL of the following criteria are met: A. For the original procedure, patient met all the screening criteria, including BMI requirements B. The patient has been substantially compliant with a prescribed nutrition and exercise program following the original surgery C. Significant complications or technical failure (i.e., break down of gastric pouch, slippage, breakage or erosion of gastric band, bowel obstruction etc.) of the bariatric surgery has occurred that required take down or revision of the original procedure that could only be addressed surgically D. Patient is requesting reinstitution of an acceptable bariatric surgical modality. A Roux-en-Y procedure following vertical banded gastroplasty or laparoscopic adjustable banded gastroplasty is considered not medically necessary for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the original procedure. Has anybody been approved for revision lately? I sent in stuff to BCBS of TX and they have requested documentation for Criteria B. I'm getting a "packet" organized. Any words of wisdom appreciated. J    — j S. (posted on April 26, 2004)

April 26, 2004
Whats a SRVG?
   — bob-haller

April 26, 2004
VGB...silastic ring vertical gastroplasty.
   — j S.

April 26, 2004
The failure is normal according to my surgeon who says the 5 year VBG faiure rate is over 80% or thereabouts:( You didnt fail the surgery it failed you....
   — bob-haller

April 26, 2004
Sounds to me like you have proof of trying to comply as far as food goes. Do you have anything to document an exercise regimine? If nothing official then sit down and write down what you have been doing. If you were making enough effort to do weight watchers for the past year I would think it would be a logical that you have also tried and complied with an exercise routine. Doesn't have to be something outrageous. A carefully worded letter from your PCP and/or WLS should work. Like Bob said the VBG or it's cousins have a known track record of failure, so this should not be such a shock to the insurance company. Go for it and fight hard!
   — zoedogcbr