Possible revision?

[ventugurl 0]

So I had a band that was removed in Dec 14 due to slipped band. Since then I have now gained about 90 lbs, the Bariatric surgeon that took it out just told me last week that he would do a sleeve or bypass on me. My BMI right now is 32, and he wants me to lose 10 lbs before he submits to insurance, my worries are what if the insurance denies me.... Is it a different approval process since it's a revision surgery??

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[Steven1954 89]

If they deny you than appeal until you are approved

[ventugurl 0]

Thank you for your reply, I'm really trying not to stress out but it's just so hard.

Sent from my iPhone using the BariatricPal App

[Steven1954 89]

I had my band removed in feb2016. Gained fifty pds since deflated a year ago. Insurance denied twice but was overturned on external appeal. You cannot let insurance co win by accepting their denial. They are in business to make money

[WLSResources/ClothingExch 3,444]

@@Steven1954, what do you mean by "external appeal?" I expect to be told very soon that my band must be removed and believe that my insurance company will deny revision to sleeve.

[Steven1954 89]

Normally the insurance co denies the revision. You are having complications which is classified as. "Technical failure of the band" That means you qualified for the orig surgery and you had it removed because of complications. Once you are denied you or your surgeon can appeal. You will prob get denied which is not unexpected. At that point you are allowed an external appeal who is unrelated to Insur co

If they deny you your best chances are with LINDSTROM OBESity assoc. You can google them or I can get you their number. NYS has external review. This is your best shot so it must be done right. You need all medical records and documentation showing complications, attempt to lose weight, and ideally while you are waiting for initial appeal, see a nutricianist a couple times to document your weight loss attempts.

In have oxford. They denied twice and insurance co was overturned on external appeal

[WLSResources/ClothingExch 3,444]

@@Steven1954, thank you for the information. By coincidence I learned this evening that NYS, it is the state which is the external reviewer. Even better, it seems that NYS always or virtually always approves in cases where the patient has a Medicare-related plan or Medicare. I do know of the Lindstrom office.

Are you in NYS? Mine is Oxford Medicare, a.k.a. AARP Medicare Complete. My source told me that the state approves if traditional Medicare covers revision, which is what I'm googling to find. My band has not been removed. I have an appointment week after next to start determining whether it still has life in it, but I doubt it. My chances of succeeding under my own steam, without the aid, are nil. I'm open to going to sleeve. Are you planning further surgery?

[waterwoman 179]

Check your insurance policy before losing any weight. Mine would cover the revisions, but only if I had a BMI of 35 with 2 co-morbidities. Because I found that out first, I gained the few pounds needed to qualify before I "weighed in" at the surgeons office.

[Steven1954 89]

WLS. I'm in NY. I have oxford commercial plan as opposed to exchange thinking about bypass

[Steven1954 89]

External. Reviewer ignored low bmi since band removal was due to technical failure

[WLSResources/ClothingExch 3,444]

@@Steven1954, thanks for the additional input. The best to you.

@@waterwoman, it's interesting how many ways there may be to go about getting revision covered. I hope the person who handles the insurance papers in my practice knows about my plan. The book is organized in a way guaranteed to make a person homicidal, so to speak.