Shot in the dark, questions about ChampV.A. and Medicare along with Realize/Lapband.

[Klu007 0]

Okay so in 2008 I had the Lap band surgery that was covered by my insurance. For the first few years it was great and I lost a ton of weight, then one day it changed. For the last 4 years I have been in constant pain and discomfort, I didn't have insurance or the disposable income to figure out what was wrong with my band until recently. It turns out that my port has flipped over completely along with a major band slip. I have regained all of my weight but the main issue is the pain from the port. If any pressure is put on my port at all it feels like someone just gut punched me. I can't let Water hit it in the shower, loose shirts only and I can't even sleep on my left side. Recently, I got insurance via ChampVA (this is not ChampUS, Tricare, or Medicare). I really need help from someone that has had surgery with ChampVA or Medicare. ChampVA will cover to remove my current band and replace it BUT.... I can't get any straight answers from them. So my first question is will they pay to replace my Lap Band with a Realize Band? I have the surgery code for the realize band which they say is covered but when I mention the realize band by name I am told it only covers the Lap Band. I talked to my doctors office and she said the realize band is covered. I think the people I spoke with over the phone are just confused but I would love to get some insight.

The main problem I am having is that ChampVA and Medicare and Tricare are all very similar programs but do things differently. I pay 25% of the allowed/negotiated amount. When I first spoke with the hospitable to get my estimated cost share I was told for an outpatient surgery it would be 500 due before the surgery. Today I received a phone call saying that since ChampVA and Medicare go by the same standards for bariatric surgery that it would have to be inpatient. So does Medicare force everyone getting a lap or realize band to be inpatient? That doesn't make since mostly because my first surgery was outpatient however due to complications I had to stay over night. The hospital is now wanting several thousand dollars to be paid prior to surgery which is supposed to happen in early May. I have spent the last few hours talking to ChampVA and they say that this surgery can be inpatient or outpatient it is based what the doctor suggests and complications. The hospital is saying that ChampVA is wrong and frankly I feel stuck with no way out.

At first the hospital rep said that inpatient was cheaper than outpatient, but when I mentioned the price difference they started denying that I had ever called. ChampVA does not do preauthorization and I can't find anything that states Medicare only does inpatient. Currently the hospital is insisting that I pay the much higher price for the surgery. If it is inpatient that is fine, but if I can have the surgery cheaper than that is what I want to do. Thank you for taking the time to read this and I look forward to any clarification.

[KateP 359]

I have no idea about your basic insurance question. But just wanted to say - don't leave this! Pain at the port site is often one of the only symptoms of erosion, which is much worse than a slip as the pain is the sign of an infection. Also, if your slip is a bad one, replacement may not be possible.

And there is virtually no difference between the Realize and the Lapband. I rarely see people talking if the Realize band nowadays.

[Klu007 0]

KateP.

Thank you for taking the time to answer. The port pain is really to a point where it is almost constant. They used a fluoroscopy machine to confirm the flipped port and band slippage, he didn't mention anything about erosion but I'm not sure if it would show up. He mentioned one reason for the port pain might be that only one stitch popped causing it to pull on the last stich along with the theory that my body might be trying to push it out along with some scar tissue. This is the same surgeon that did my original surgery and he himself recommended the switch to Realize since people seem to be having less issues with the port. You can see my port sticking up through my skin or even with a tight undershirt, which I personally find unsightly.