Eroded Band To Gastric Sleeve - Requires Six Month Program?

[FXDF2008 14]

I'll try to make this short and sweet

I had lap band surgery in February of 2007. I was diagnosed as eroded in November of 2011 and was removed in March of 2012. I elected to switch to a new surgeon to perform the gastric sleeve surgery who required that I wait six months after the removal of my band in order for the scar tissue to heal and the adhesions to settle down. He also required that I have an upper GI, an upper endoscopy and an esophogeal monometry in order to ensure that I would be a good candidate for a high pressure system like the sleeve. I passed all tests with flying colors.

I have BCBS-AL. They covered the removal of the band and the subsequent tests mentioned above; however, they have denied my pre-detemination for sleeve surgery until I complete a six month weight loss management program. They stated that since I do not currently have a bariatric procedure that I am essentially having to requalify all over again.

Is it me or does this make absolutely no sense at all! Their policy plainly states that they cover repeat surgery as a result of band erosion with no exceptions to that policy listed. We are appealing based on the fact that my surgeon determined that it was medically necessary to perform the revision in two steps and that it would have ben unsafe for me to do otherwise.

Has anyone had a similar experience? I feel like I am the only one who has ever had an eroded band and had to wait six months to complete the process.

Help!

[Jasmine7 0]

I am having this problem with my insurance too but I have CIGNA. I don't want to go through a 6 month long doctor supervised weight loss plan but it looks like I have no choice. I feel out of control right now with my eating.

[FXDF2008 14]

I am having this problem with my insurance too but I have CIGNA. I don't want to go through a 6 month long doctor supervised weight loss plan but it looks like I have no choice. I feel out of control right now with my eating.

I hear you Jasmine. I went nuts after my band was removed. It's amazing how quickly the weight comes back. Now I'm miserable and feel the way I did pre-band which is why I don't want to have to wait another six months. The company I work for is in the process of being bought out so there is a very real possibility that I may not be covered in six months.

I have started the six month diet (earlier this month) but that puts me into June at the earliest to have my surgery. By then it will have been fifteen months that I will have been without some sort of Bariatric assistance. It just doesn't make sense why the insurance companies would make us do this after already having a band.

Why are you revising to the sleeve?

[Jasmine7 0]

Hey Fx,

I was banded in 2006. I had success for the first year but then I had several slips, terrible heartburn, acid reflux, you name it. I suffered for several years trying small fills, no fills and then had an upper GI. They discovered a hiatal hernia, more band slippage and inflamation. I was done. My band was removed on October 4. The insurance nurse, (for lack of a better way to discribe her) got a denial for a sleeve revision. My BMI is 31 and they require a 37 with 2 co-morbidities or a BMI of 40 with none. I have arthritis but nothing else. So...there I stand. I am forced to do yet another diet that I know will not work. I've been trying that route my whole adult life. Not to be a negative ninny but I can't deal with another failure. It's very depressing

[FXDF2008 14]

Hey Fx,

I was banded in 2006. I had success for the first year but then I had several slips, terrible heartburn, acid reflux, you name it. I suffered for several years trying small fills, no fills and then had an upper GI. They discovered a hiatal hernia, more band slippage and inflamation. I was done. My band was removed on October 4. The insurance nurse, (for lack of a better way to discribe her) got a denial for a sleeve revision. My BMI is 31 and they require a 37 with 2 co-morbidities or a BMI of 40 with none. I have arthritis but nothing else. So...there I stand. I am forced to do yet another diet that I know will not work. I've been trying that route my whole adult life. Not to be a negative ninny but I can't deal with another failure. It's very depressing

Jasmine,

I sent my own three page appeal letter explaining to BCBS-AL why I shouldn't have to complete the six month weight loss program and they approved my surgery!!!!!!!!!!! Be your own advocate. Write your own appeal letter. I'm a firm believer that most insurance coordinators just go through the motions and will accept anything the insurance companies tell them. If you need a copy of my letter as an example just let me know and I'll send it to you. You shouldn't have to suffer after the band failed you medically.

[timetobefree 74]

Congrats! Glad to hear that your surgery was approved!