Are the insurance requirments the same?

[AKessler731 2]

Hi!

This is my first post so I'm sorry If I'm posting this in the wrong area but I didn't see anything like this in the insurance area. I just went to my surgeon today. I'm 5 years out with my lap band and have gain almost 50 of the 85 lbs I had lost from the band back. I'm very frustrated. My dr asked me if I'd thought about revising to the sleeve. It had crossed my mind but I just wasn't sure. They are supposed to be sending the information over the United Health Care to see what my requirements will be. But I am curious if any of you may know. Right now my BMI is 38. Will it need to be over 40 like it was when I had the lap band done? Or will they take into consideration that it was over 40 before? To be at 40 I would need to gain 8 lbs. I can do it if I need to, but thats kind of defeating the purpose. lol. I'm also curious if I'll have to do the psych visit, nutrional counseling and exercise class again. I'm fine with the two week liquid diet. It sucks, but I can do it. Thoughts?? Also I'm wondering if I will need to pay my whole deductible up front? I'm sure I wont be able to get it done before the end of the year so I know my deductible will start over. My individual deductible is $1500 I think. I know my family deductible is $2800 with $3000 max out of pocket per person, $6k max out of pocket for the family. Thank you for any insights!

[Sharon1964 2,530]

The only one who will really know is your insurance company. Since it's been five years since your last surgery, I would expect you would have to start over. However, your insurance company might have different requirements for a conversion surgery than for someone who has never had one before (I'm assuming you have the same insurance).

The only one who can answer about your deductible is your surgeon and/or your hospital. I had to pay the majority of it up front.

[RickM 1,747]

While specific insurance policies may differ, typically the industry standards of 40BMI (or 35 with co-morbidities such as hypertension or sleep apnea) still apply. I have seen some that cover the revision with lower BMI if there was a mechanical problem with the band - slippage, erosion, etc. Any chance that you have developed any of those co-morbidities since your last surgery? It would be a shame and counterproductive to have to gain weight to qualify to lose weight, but that is sometimes how the game has to be played (ankle weights, anyone?)

The psych evaluation is pretty much a standard provision, though the requirements for nutritional and exercise programs vary widely. Somebody in the process (the hospital or surgeon's practice typically) will usually want the deductible up front and sometimes an estimate of the copay as well.

[AKessler731 2]

I figured I'd follow up on my post. I got the call today that the revision is covered. The only things I need to do are the Nutritional Counseling, Psych Eval and get a letter of medical necessity and medical clearance from my PCP. I do still have to have a BMI of 35+ with a co-morbidity or just a BMI of 40. Which means I technically need to gain 8 lbs. But someone on another page recommended that I just wear some 10lb ankle weights to my weigh in appt. lol. I'm starting college on Monday so I'll be shooting for mid March, during my spring break from school, to get the surgery done. Just wanted to let ya'll know what happened with it.

[hellos 19]

I have Kaiser so not sure if my story is going to be the same for other insurances. I did not have my lap band put on by Kaiser at that time I had another insurance group. I got down to my goal weight. But I did have Kaiser remove my lap band 2 years ago do to slippage. Kaiser doesn't believe in the lap band so they wouldn't put another one on, they will only do sleeve or bypass surgery. I went back 2 years later on 12/14/15 to got my sleeve. I only gained back 15 pounds so my bmi was not that high. They said that I would automatically qualify because it is still considered revision surgery and I was starting to gain weight back. I didn't do any classes, pre diet, no psych evaluation, or anything.....I just had to do 2 days before surgery on a clear liquid diet. I did of course pay my deductible but that was it.