AceBlaque

When I decided to pursue the revision the surgeon who performed my initial gastric sleeve performed my EGD. When his staff submitted the package for insurance approval that was all submitted, that submission was denied. Instead of submitting an appeal I opted to immediately see a bariatric physician that I could possibly get approval with within the last quarter of the year. After talking with my new physician a second EGD was performed, an abdominal ultrasound was done to view my gallbladder, an ultrasound on my legs and arteries and a stress test to actually monitor how I performed and breathed while cycling. The stress tests showed I had the capacity of someone 30 years my elder and showed a sac full of gallstones that my initial surgeon didn't want to remove and never did tests to show there was an issue. When these were submitted the 2nd time to my insurance, I was approved immediately for a revision, from a gastric sleeve to a duodenal switch. Although my first surgeon didn't submit and real problems with my sleeve, my second surgeon saw that a portion of the stomach was left during my initial surgery that should have been removed. My initial surgeon would not admit that there was an issue in the submission to the insurance company which was a cause of the initial denial. I'm now approaching my 3month post-op revisional surgery. I felt defeated after speaking with my first surgeon...stay strong you still have options Sent from my SM-N950U using BariatricPal mobile app

I'm so glad to know the wait period is less. Our Medicaid plan that I work for has to have to our members travel out of town because of the provider that is credentialed with us. We pay travel reimbursement, so make certain that you inquire about that if it's needed. Sent from my SM-N950U using BariatricPal mobile app

I am employed by a medicaid insurer, look on the back of your card and call the benefits line listed. Once you reach a rep, tell them you would like a list of providers sent to you for bariatric physicians and a list for behavioral health providers (for your psych evaluation later)...they will send all of the providers that are credentialed with their company that accept your insurance. That way you don't have to call only the ones that you know are doing bariatric surgery. Also, if you don't find a good one that takes your Medicaid please ask if they are willing to do a 'Single Case Agreement'...this will allow your insurance to partner with the hospital and surgeon to receive services and payment for your case only. Don't give up, there are always options! If you have any questions, don't hesitate to ask...everyone deserves a chance to become the healthiest they can be! Sent from my SM-N950U using BariatricPal mobile app

Thank you, I think your approval will come quickly for you! Keep us posted, can't wait to hear the good news!! Sent from my SM-N950U using BariatricPal mobile app

Hello, I have BCBS(not Tx)...the coverage was for one bariatric procedure per lifetime and in order to get a revision approved, there had to be an issue from the primary procedure. Once my physician proved my primary procedure failed (proved through EGD tests, existing comorbidities, gallstones/gallbladder complications that would be removed during revision) my revision was approved very quickly without a wait period. In my insurance submission, all of the test results were included even my gym membership to show I was continuing to make efforts on improving my health. Sent from my SM-N950U using BariatricPal mobile app

Hello! Yes, I used my Nurse Practitioner for my insurance submission. I've had my NP sign off on one of my bariatric surgery's and had no issues what so ever, in fact it was easier to have my NP involved because she was very knowledgeable and supportive in my process. Sent from my SM-N950U using BariatricPal mobile app

No problem, I was a similar situation as you but my issue was that I had to keep the position because of the insurance coverage, im glad your insurance is through your spouse so that it isn't an issue with your surgery or staying on a job that is stressful to what you are trying to accomplish. If you have any questions on how to get your disability/FMLA, inbox me...keep us posted! Sent from my SM-N950U using BariatricPal mobile app

You have a few options depending on how soon you want to leave your current job...you can take short term disability which can run concurrent with your FMLA and protect your job while you have surgery and are healing. You would still be able to receive a portion of your pay while healing and preparing/searching for your new job. That would give you up to 12wks without worrying as much or dealing with on the job issues that are often stressful. Your physicians office will know the process as well. Sent from my SM-N950U using BariatricPal mobile app

Does your current job offer short term disability or FMLA...or would your job you're seeking offer either? Sent from my SM-N950U using BariatricPal mobile app

Try to stay calm and relax...it's most likely due to the surgery. I had a revision and gallbladder removal and gained weight immediately after. My doctor said he would have been concerned had I not because of the fluids, antibiotics and steroids I was given. After about 2wks, the weight started sliding off just like he said. He assured me that bc of the diet changes bc of the gallbladder removal, I would actually lose weight instead of gain. He stated that the frequent defication and lack of the gallbladder being able to digest fatty food would lead to some weight loss itself even though I had had a revision. You will be fine! Continue to eat healthy and follow your doctor's orders and numbers on the scale WILL decline! Let us know how your appointment goes Wednesday. Sent from my SM-N950U using BariatricPal mobile app

I tried sending this to you as a message but I was unsuccessful so I'm reposting here. It was something I shared here on BP with some facing approval. Although im not a 'know it all' anything that I know that may help you, i'll be happy to share. If you have any questions let me know. I shared/posted this a few weeks ago with someone facing insurance approval too: I had a sleeve gasterectomy in spring of 2015 and had no issues getting approved. In spring of 2017, my original surgeon and I saw that a full duodenal switch was needed for the absorption component so yhe process for approval began again...EGD, psychological evaluation, PCP visits and approval etc. Since BCBS only covered one bariatric procedure per lifetime, The situation with the second surgery is that it needed to be proven to be medically necessary and that I had been compliant with the sleeve gasterectomy in 2015. After the completion of my tests and visits, my package was submitted to my insurance company. As you guessed it, DENIED. I knew I had to act quickly since it was denied in the fall, this meant my deductibles has been met and in order to not have to pay them again in 2018, I needed to try to push for approval before 2017 ended. I knew that the appeal could take longer than I would need and after what decision I would be given, I would either have to have the surgery in 2018(deductible) or have to start the process from the beginning. Although I was frustrated about the denial, I decided to start doing what I knew to do, fight. You see I work for a medical insurance provider and advocate daily for members to receive the care that is needed, be it from physicians or the insurance company. I had assisted many members before in getting various approvals for different treatments that was needed to better their life. I went over all the things that I knew a review board and medical director would want to see/know before granting me a 2nd opportunity. Upon doing this I realized that my surgical team did not fit my needs this time around and to appeal the initial denial would be pointless since the evidence/tests needed for the insurance approval were not done by my original surgeon. I did additional research and found a surgeon in Texas that was well credentialed, accepted my insurance and also did initial appointments by phone since I was a patient from another state. After reviewing ALL of my medical history that was sent to him and discussing the prior denial, we forged forward. After phone 'visits' I was scheduled for an EGD with this doctor along with a 3 part stress test(breathing, legs and heart to check for clotting and exercise)...during the EGD I was also given a ultrasound of the gallbladder. This doctor was extremely thorough and was making sure that I was given every possible chance for the insurance to not deny me. When the package was submitted after all of the tests, I made sure to tell my insurance coordinator at the surgeons office additional things I wanted included such as my fitness gym contract, diseased gallbladder ultrasound, receipt from latest pcp appointment(that insurance company didn't show in their records)...I knew I had a better chance at approval if BCBS saw that not only was I being compliant but that I needed a cholesctomy(gallbladder removal) and that I would pursue the 2nd surgery until it was granted. With the cost of treating my comorbities, I'm sure the insurance saw that it was less expensive to grant the surgery than it was to treat the ailments that existed bc of my weight. By the amazing powers that God put in place, I was granted the second opportunity to change my life. My surgery took place December 14, 2017. Prior to surgery my co-morbidities were high cholesterol, hypertension, diabetes(with injections daily), edema in lower extremities. Please don't give up!!! My apologies for the long reply but I hope it helps someone that needs the strength to keep fighting. Sent from my SM-N950U using BariatricPal mobile app

Good morning, what tests did your Medicaid request you do. What tests did your doctor/surgical team have you complete? Sent from my SM-N950U using BariatricPal mobile app

Omg!!! I feel like I just got approved all over again by what you getting yours!! I'm super proud and excited that you didn't give up!! March is right around the corner, yayyyy!!!! Sent from my SM-N950U using BariatricPal mobile app

Thanks, you're in my prayers, it was my prayer when I submitted to my insurance that God placed the needed people in place that would be reviewing my case. I thought i had gotten denied bc my Drs office nor myself had heard anything from my bcbs in over two weeks, so I called to followup. The precertification dept told me that my case had been dismissed for lack of receiving my clinicals. I had to give them the date that tge clinicals were sent in and had been confirmed by bcbs. The pre-cert dept then said I was correct and that they didn't know why It had veen dismissed and that tgey would re-enter my information and submit it for review. It so happened that the original reviewer had the day off and my case was sent to another nurse that approved it the same day that I called. Make sure to ask your doctor if he/she will do a peer-to-peer conversation if you are denied. Please note that being affected mentally by weight complications is a reason for the surgery to be "medically necessary" (as long as the patient is psychologically cleared for the procedure) and some insurance companies will take that into account. Please keep me posted! Excited for you already! Sent from my SM-N920V using BariatricPal mobile app