Band To Sleeve

[crystal525 26]

So here's my story...

Banded since November 2008. Lost 76 pounds (254 to 178, size 18/20 to size 10). Alot of the weight was lost when I was too tight to get/keep much down. No significant loss in the last 2 years. I get recurrent fevers every 6 months or so, for which I've had numerous tests for -- they thought I might have an auto immune disease but all testing was negative—my surgeon thinks it might possibly be my body rejecting the band, but we don’t really know. Fevers lasted about 24-48 hours then I was back to normal! ...and then my pouch got dilated. I was completely unfilled in December 2011. It has corrected itself, but I’m still gaining. I really started gaining last March when I was getting really bad heartburn and was way too tight (I believe my dilation started then...), at first it was a small gain. Since the unfill, I have gained 25 pounds in 4 months. Ugh...

So—I saw my surgeon today and I start my 90 day program for the sleeve next Tuesday. Two surgeries--I will be getting my band out by the end of the month. I am concerned about insurance approval because I'm afraid they only consider it a revision when it’s done in one surgery and my BMI is under 40. But I’m ok with two-step process because of the leak issues…which I'm also scared to death of. The insurance person at my surgeon’s office doesn’t seem to think my low BMI will be an issue since I had the band (I still have the same insurance that covered my band placement if that matters). The policy isn’t very clear to me when I read it (is it only revision in one surgery…that is the question…???):

1. Repeat Bariatric Surgery:
   

Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction, stricture, erosion, or band slippage.

Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:

1. Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   
2. Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   
3. Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments.
   

I so didn’t want to be here again. I cannot regain all my weight. My body hurts already with where I’m at right now. If everything goes as planned, my 90 day program will be up Jul 9 and I’ll be sleeved at the end of July.

Wow-this is moving quickly. I knew I wanted to do it, but was scared to pull the trigger...I just really decided to go for it when I saw that I gained another 7 pounds at the dr. office this morning.

Been reading for a couple months...looking forward to posting here (I used to be on lapbandtalk.com).

Crystal

[Cmullinvegas 39]

Good luck to you. I drove my friend to Tijuana 4 years ago to get a band. I have watched her struggle since.

[GivingItMyAll 168]

I think you qualify under the second bullet, up I am no insurance expert. Good luck. I hope it all goes well for you.

[Wheetsin 714]

First, I don't see anything in the verbiage above that indicates they have to be done in the same procedure. Is there something in there that you're reading that sounds like it to you, or are you just curious? If that's the totality of the requirements you should be ok.

I just had my revision to sleeve surgery last week. My band was removed September of last year after a "profound slip" that didn't give me any real option for rebanding (which I wouldn't have wanted anyway). I think it was slipped for about 3 years (I had it back in early 2006). Given the stats of revision complications, I personally would not have done both in one procedure. My surgeon requires a minimum two month period in between. Mine took longer because I first had an insurance denial, then had to write my appeal -- the denial was overturned and I was approved, and then our insurance changed so I was back to square one.

Today was my first post-op appointment. When I was weighed pre-op I didn't look, I was just not wanting to know the number. They told me today and had gained back about 50 lbs in my 6.5 months without a band. I didn't eat crazy stupid and that's more regain than I would have expected, but.... it will come off.

Please ask any questions you have. I'm only a week post-op but lived with a band for a long time (was a mod on lapbandtalk until I had a baby and didn't have much time anymore).

[kimmr 5]

Hey Crystal,

I'm in your exact same boat, but I've gone through the revision from band to sleeve. Here's my deal:

I have Aetna insurance, and I have the exact same wording in my policy that you posted above. However (I'm not sure if you have this or not), I have a $10,000 lifetime bariatric max. As such, if my surgeon was willing to, I wanted to do it all in one surgery. The hospital portion (vs the surgeon's fee) is the much more expensive side of the equation when it comes to surgery (at least for me), so going through two surgeries with a $10K max was sort of financially impossible for me.

So anyway, my surgeon was willing to do the revision in one surgery. She put together a pretty good argument for me, and we submitted for approval. Aetna approved me in less than a week. They approved a lapband explant and a vertical sleeve, so exactly what I needed. I'm not sure which bullet point they approved me under, but frankly, I don't really care...I just needed a pre-approval.

I did my revision 9 days ago.

[crystal525 26]

Thanks all!

Kimmr--I looked at my specific company policy and my bariatric max is unlimited, so no issues with that.

GivingItMyAll--I think I qualify under 2nd bullet also...

Wheetsin--I got the impression that the insurance companies only considers it a revision if it's done in one surgery (because I'm having to do the 3 month program again before the sleeve is submitted for approval). I'm worried that my band will be removed and I won't qualify for the sleeve because of my BMI and no comorbidities... I'm going to see if the insurance person will just submit both right now without waiting for the 90 days...I'll copy this portion of my policy and email her.

Just got a call to schedule my removal...more news soon as I hear something!

[sperry71 1]

This is what happened to me. I have Blue Shield HSA ( Health Saving Account) I have had this insurance for 5 years now. My out of pocket was $5,500 deductable. (Once I pay deductable my family I medical and prescriptions are free for the rest of the year) was banded 6/09 six months into it I am convinced my band had slipped. It took me a year to convince my doctor that something was wrong. He thought I was over eating. He finally realized it did slip but he was not a preferred provider with my insurance any more. I was going to have to pay $7,000 for him to remove it convert it to the sleeve. I could not afford that and he was not offering me a payment plain. It took me 6 more months to find a doctor to remove my band. The doctor removed my band 6/11 (it cost me another $5,500) and he told me because it had slipped and was in that position for so long I had to give my stomach to heal. He told me to come back in to months. So I am thinking cool at least I wont have to pay my deductable again. 8/11 I go back and the doctor would not even see me. His insurance biller cut me off and said that I don’t qualify for it any more because my BMI was to low now and I didn’t have my other health problems any more. I told them that it was not my choice to remove the band it was medically necessary. I was then told to come back when my BMI was high enough. I go back 10/11 my BMI was 35 but I didn’t have two other health problems any more. I am devastated at this point. So I call my insurance company crying my eyes out and I told them everything that was going on. I was told that the doctor need to call and tell them that I was medically necessary to have it removed for me to get my authorization approved and I could bypass the 6 month consultation with the detestation. I went back to the doctors’ office they still would not let me see the doctor and his insurance person said she never head of anything like that before and she would not call. So I finally found another doctor to work with me and I explained everything to him. I got my approval letter first time out and my surgery is in 7 days. The bad side to this is that I gained ALL my weight back and then some, my health problems are back and I have to pay another $5,500

[Wheetsin 714]

A revision doesn't have anything to do with the length/lack of time between procedures. I was 6 months apart and am still a revision. You're just having a former surgery 'revised' to something else.

Best of luck.

Wheetsin--I got the impression that the insurance companies only considers it a revision if it's done in one surgery (because I'm having to do the 3 month program again before the sleeve is submitted for approval). I'm worried that my band will be removed and I won't qualify for the sleeve because of my BMI and no comorbidities... I'm going to see if the insurance person will just submit both right now without waiting for the 90 days...I'll copy this portion of my policy and email her.

[LilMissDiva Irene 3,282]

So here's my story...

Banded since November 2008. Lost 76 pounds (254 to 178, size 18/20 to size 10). Alot of the weight was lost when I was too tight to get/keep much down. No significant loss in the last 2 years. I get recurrent fevers every 6 months or so, for which I've had numerous tests for -- they thought I might have an auto immune disease but all testing was negative—my surgeon thinks it might possibly be my body rejecting the band, but we don’t really know. Fevers lasted about 24-48 hours then I was back to normal! ...and then my pouch got dilated. I was completely unfilled in December 2011. It has corrected itself, but I’m still gaining. I really started gaining last March when I was getting really bad heartburn and was way too tight (I believe my dilation started then...), at first it was a small gain. Since the unfill, I have gained 25 pounds in 4 months. Ugh...

So—I saw my surgeon today and I start my 90 day program for the sleeve next Tuesday. Two surgeries--I will be getting my band out by the end of the month. I am concerned about insurance approval because I'm afraid they only consider it a revision when it’s done in one surgery and my BMI is under 40. But I’m ok with two-step process because of the leak issues…which I'm also scared to death of. The insurance person at my surgeon’s office doesn’t seem to think my low BMI will be an issue since I had the band (I still have the same insurance that covered my band placement if that matters). The policy isn’t very clear to me when I read it (is it only revision in one surgery…that is the question…???):

1. Repeat Bariatric Surgery:
   

Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction, stricture, erosion, or band slippage.

Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:

1. Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   
2. Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   
3. Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments.
   

I so didn’t want to be here again. I cannot regain all my weight. My body hurts already with where I’m at right now. If everything goes as planned, my 90 day program will be up Jul 9 and I’ll be sleeved at the end of July.

Wow-this is moving quickly. I knew I wanted to do it, but was scared to pull the trigger...I just really decided to go for it when I saw that I gained another 7 pounds at the dr. office this morning.

Been reading for a couple months...looking forward to posting here (I used to be on lapbandtalk.com).

Crystal

Hello Crystal, welcome to VST!!

I'm also a revision from band to sleeve as of 9/15/10. IMPO, my sleeve surgery was far more successful for me than my band ever was. I'm hoping all goes smooth with your surgeries/insurance issues.

Keep us updated on how you're doing! Read up here and there, especially the revision forums. All the best and many blessings!!

[crystal525 26]

So I thought I'd update my band to sleeve thread for those who are in the same position.

I was banded this past Monday, 1/14. My surgery took 5 hours because of all the scarring caused by my band and because I had a new large hernia to repair (I also had a hernia repaired during my band placement in 08). My doc said my surgery was a very long one and was glad he didn't try to do it in one procedure!! In addition to the staple line he stitched completely over the staples to reinforce it. My leak test (which I have read not all docs do) went perfectly. I know leaks can still happen but for me this gives me some peace of mind. I stayed 2 nights in the hospital (mostly because of how far I am from the hospital but also because my surgery was so long).

I came home with a drain and an onQ pain pump (auto drip of pain meds directly into stomach). As of today I'm trying to limit pain meds to twice a day. I'm not having nearly as much gas/shoulder pain as I had with my band, which is a relief! I'm able to drink my fluids (slowly) and eat Jello and broth easily. Protein shakes....It's taking effort but I'm able to get at least half in. Mixing Protein powder with half Water, half milk is much better than the pre-mixed ones for me...it's thinner.

No heartburn to speak of and I had major heartburn before this surgery. That was a huge worry for me since I know increased reflux is common in sleeves. A little nausea in the morning usually related to trying to drink a Protein shake before taking my anti-nausea med.

Thankfully I'm never hungry. But I'm not full either. The best way I can describe it is that feeling after you eat and you are no longer full but know you are not ready for your next meal any time soon. This also worried me knowing my doc requires a 3 WEEK CLEAR liquid diet with the only exception of the Protein drinks. Then it's another couple weeks of full liquids, then mushies...

Overall I'm very happy with things so far! Sorry for the length of the post! Ask any questions you'd like and I'll help if I can.

Crystal