BCBS Fed - anyone have revision approved?

[VDLT 244]

I was self pay for band in 2001 and did well with weight loss at the beginning. Had some fills and unfills around 2009 and after that never felt right. Was too tight and did not eat well. Had imaging studies in 2011that showed esophagitis, gastritis, and a hiatal hernia. I had terrible shoulder pain and heartburn almost daily. Finally had the band emptied in 2013 but still have symptoms.

Had a surgeon send in a letter in 2011 but was denied. I never got a copy of the denial. I want to try again but I have not been at a 35 bmi for two years. Anyone approved due to medical necessity for similar circumstances?

Also my preferred surgeon is not at a center of excellence and I really want him to do my surgery. I have thought about self pay but am scared that if I develop complications since I have had band for 14 years that insurance will not cover the complications.

Thank you for your thoughts!

[SleeveandRNYchica 1,155]

Following... I am in the process for revision with FEP... I do think they require that BMI of 35, but if you have other co morbities, maybe they will consider. I do believe you will pay more out of pocket by not using a center of excellence. I am in month two of 3 month supervised diet....my original surgery was done abroad and paid for by BCBS. I have some medical issues as well. I would just be sure to get your PCP to write a really great letter of necessity and follow the requirements to a T. Everything has to be done again.

[JK90 4]

I was banded in 2010 (private pay) and never found my sweet spot. I was fed up with it 18 months later and quit going to the dr for fills and ended up gaining all of my weight back. Then, over the past year I've had a lot of trouble keeping solid food down (regurgitation) and when it got to a point where it was happening on a daily basis I went in to my Dr's office and after an upper GI they told me I had esophageal dysmotility. My esophagus wasnt doing the muscle motion needed to help me swallow and overall that my body wasn't agreeing with the band anymore and it needed to come out. I couldn't afford to pay for another out of pocket surgery so I asked what the cost was for a revision like mine and they told me that if you have a hernia (I did) and/or are having true medical problems that are caused by the band then bcbs would cover my revision. This turned out to be true, but it still wasn't cheap by any means. I paid about $5500 total for the dr, my egd and the surgery center's fee. Good luck with getting your revision!

[VDLT 244]

@ Thank you so much. I just pulled some old medical records and one doctor has me as being an inch shorter than another so with that info I am techinically over the 35 BMI for the two years. Might try to get them to pay. Rather do the surgery now than wait for 3 months to do a medically supervised diet but if they request it I guess I will need to try. Did you call BCBS Fed first or did you just submit your paperwork. Just curious if I should call them or just send my surgeon my paperwork to be submitted.

[VDLT 244]

@@JK90 thank you for sharing your experience. Did you have to do the supervised diet?

[JK90 4]

@@VDLT no, I didn't.

[SleeveandRNYchica 1,155]

I met with the surgeon first. The bariatric coordinator contacted the insurance company, but I already knew what I needed to do. It is on page 67 or something like that of the handbook. No matter if you have standard or basic requirements are all the same. My drs office will not file with the insurance until I have completed all the requirements. I so far have completed psych eval, got my weight history, and I have my second NUT appt on 7/15 it's an online appt. I need to get my letter of necessity from my PCP. Good luck to u!

[SleeveandRNYchica 1,155]

I was banded in 2010 (private pay) and never found my sweet spot. I was fed up with it 18 months later and quit going to the dr for fills and ended up gaining all of my weight back. Then, over the past year I've had a lot of trouble keeping solid food down (regurgitation) and when it got to a point where it was happening on a daily basis I went in to my Dr's office and after an upper GI they told me I had esophageal dysmotility. My esophagus wasnt doing the muscle motion needed to help me swallow and overall that my body wasn't agreeing with the band anymore and it needed to come out. I couldn't afford to pay for another out of pocket surgery so I asked what the cost was for a revision like mine and they told me that if you have a hernia (I did) and/or are having true medical problems that are caused by the band then bcbs would cover my revision. This turned out to be true, but it still wasn't cheap by any means. I paid about $5500 total for the dr, my egd and the surgery center's fee. Good luck with getting your revision!

Are u FEP BLUE within the federal program?

Each state with BCBS has different requirements.

[ReaderGirl 17]

I have BCBS in Texas of course wouldn't pay for my revision so I did self pay.

[SleeveandRNYchica 1,155]

All the BCBS' have different requirement FEP BLUE Federal pays for revision after all requirements are met AND there is proof of compliance with 1st surgery.

[VDLT 244]

@ I am fed basic. I sent a letter to my surgeon's office and Ned records showing my side effects and weight for the last few years. They said it might be enough and to get my psych evaluation done. Doing that in two weeks and we will submit. We shall see! Thanks so much.

[SleeveandRNYchica 1,155]

@ I am fed basic. I sent a letter to my surgeon's office and Ned records showing my side effects and weight for the last few years. They said it might be enough and to get my psych evaluation done. Doing that in two weeks and we will submit. We shall see! Thanks so much.

I think you will be okay! Keep me posted.

[newlife082318 10]

I called BCBS Fed yesterday b/c my lapband has slipped and is causing severe issues. I was told since it is a "complication" that the surgeon says must be rectified, then they will pay for it but they still need to do precertification. I don't have to go through the whole testing/dieting/psychoanalysis stuff again since it's a complication and needs immediate attention.

[SleeveandRNYchica 1,155]

I called BCBS Fed yesterday b/c my lapband has slipped and is causing severe issues. I was told since it is a "complication" that the surgeon says must be rectified, then they will pay for it but they still need to do precertification. I don't have to go through the whole testing/dieting/psychoanalysis stuff again since it's a complication and needs immediate attention.

They are making me go through whole kit and kaboodle again. Someone else in here with complications had to do everything again.... Ugh! I think my insurance coordinator at drs office is not communicating with BCBS properly...

[KeepCalm 223]

I was told today by my BCBS that I might have to do it all again because it has been more then two years - which means instead no diet months - doc is having me do 3 until I find out if it's more for sure - I'll have to do 6... which means surgery in January instead of October/November