Denied revision surgery - Anyone have luck with asking a 2nd time?

[betrthnever 107]

Long story short - lap band in 2008, lost 80 pounds gained 60 back. Was denied by BCBS for a revision to Gastric Bypass back in November of last year with a BMI of a little over 35. BMI is now at 37. I did not contest the denial as I was just having an unrelated surgery and was also told that I had to have a BMI of 40 for 5 years before I would even be eligible again. I will call my Dr. to go in again for another consultation to see if they will resubmit to my insurance company.

My question is, has anyone been denied by their insurance company for a revision but then was successful a second (or third) time around with insurance at a BMI of 37-38 with no other morbidity issues? I am not even sure if my lap band Dr. will even service my band anymore as it was deemed a "failure" and the insurance won't pay to have it removed (and I'm not having any complications from it so i'm OK with it staying in).

Thank you

[losing_the_band 133]

I actually just got approved for revision from band to bypass, and I had a band replacement in 2011 after my first band slipped severely. I had two denials for the band-to-bypass revision, and my surgeon finally did a peer-to-peer appeal and got it reversed. I think it's fairly standard practice for insurance companies to deny the first attempt at revision appeal, because they're hoping you just give up. Mine was denying it because they kept saying that I couldn't prove any technical malfunction of the band, even though I was having severe reflux and was unable to tolerate any Fluid in the band anymore. I would recommend contacting the Lindstrom bariatric law group, since they will handle the appeal for you. I got a quote from them, since I was going to use them if the peer-to-peer appeal was denied.

I would first recommend trying to find a surgeon that specializes in revisions, though. We're special cases, and we and our surgeons can't treat our stomachs like ones that have never been touched. With a doctor that does a lot of revisions, their staff will be more experienced in how to finesse the insurance approval/appeals. If I'd had a revision surgeon when I had to have my band replaced in 2011, I probably would have gone with a different surgery instead of a replacement. I believed my insurance coordinator, though, when she said I didn't have a chance at getting it approved, so we didn't even attempt to get a conversion to another surgery approved. I know now that I would have actually had a really good chance of it getting approved, since I'd had a major complication.

[betrthnever 107]

losing_the_band thank you very much for sharing your story. I believe I gave up easily because I was literally going into another surgery (prolapsed bladder) and just wanted to put my energy into healing. But now, 9 months out and recovered from my surgery, I'm ready for a fight! My surgeon is well experienced with revisions and I was told last year that mid-year they did more band revisions then actual bands. I believe in their skill but will they fight for me? I'm not sure.

I've suffered from GERD when my band was tight, and I was told that I was STILL suffering from it even tho I had no clue that I was. My band was like everyone's band - a foreign object wrapped around my stomach. I believe that there are some for who this works well (and for a couple of years I worked my band well and was considered a "success", too).

Question for you tho - what was your BMI at the time you appealed?

[losing_the_band 133]

My BMI was around 36.5-37.