New letter submitted for my revision appeal

[brittu 42]

So I've been in a 14 month fight for coverage of a revision from lap band to a sleeve. I should finally know the outcome this week. Over the weekend I found some great info on policies and standards of care for revisions. I put together one final letter that I overnighted yesterday.

Just in case it's useful to anyone (I sight the policies of Medicare, 8 other insurance companies, and the ASMBS) I'll post a link to my blog.

Thanks,

Britt

vsgappeal: Final Letter - Why revision doesn't require a high BMI

[Lynn B 0]

Hi Britt - I am just starting to research band to sleeve revision (my band is still in place but unfilled, my pouch is dilated). I wish you well and hope you win this battle soon. I've reviewed my ins policies stance on revision and it does appear that they will also only revise if you don't have "adequate" weight loss - duh, they'll undo you but not do you back up unless your still heavy?? I don't get it. I guess in this scenario I'm lucky, I have lost more than 50% of excess body weight but I'm not within 30% of a normal or goal weight. My doc is doing preapproval now while I research and make up my mind but I'm hoping that it goes through without a hitch (if not I'll be visiting your blog!) ~ Thanks!

Reoperation and Repeat Bariatric Surgery:

Coverage Policy Number: 0051

CIGNA covers surgical reversal (i.e., takedown) of bariatric surgery as medically necessary when the individual develops complications from the original surgery such as stricture or obstruction.

CIGNA covers revision of a previous bariatric surgical procedure or conversion to another medically necessary procedure due to inadequate weight loss as medically necessary when ALL of the following are met:

? Coverage for bariatric surgery is available under the individual?s current health benefit plan.

? There is evidence of full compliance with the previously prescribed postoperative dietary and exercise program.

? Due to a technical failure of the original bariatric surgical procedure (e.g., pouch dilatation) documented on either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD), the individual has failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body weight or failure to achieve body weight to within 30% of ideal body weight at least two years following the original surgery.

? The requested procedure is a regularly covered bariatric surgery (see above for specific procedures).

NOTE: Inadequate weight loss due to individual noncompliance with postoperative nutrition and exercise recommendations is not a medically necessary indication for revision or conversion surgery and is not covered by CIGNA.

[Gigi_Girl 77]

Hi, I saw your old posting. Did you ever get approved?

I am going thru that process now with BCBSAL and have received two denials due to once in a lifetime benefit. Nevermind, the darn band has a leak!

Anything from your experiences that you can share would be appreciated.

Gigi