Hypothetical Slippage Question

[Mahoney 1]

I'm just wondering if anyone has any insights on something I'm thinking about. What if I do get approved for surgery by my insurance, and at some point down the road I need surgery to fix something like a slippage problem at a point where I'm at what the insurance company considers a normal weight? Would they typically cover a repair of a lap-band even though I no longer met any of their BMI type requirements?

Thanks!

Bob

[bbrecruiter2000 1]

Bob,

Thats a great question. I wondered that as well. I also wondered if you switched insurance companies and had the same problem, what could or would they do? I am sorry that I do not have the answers to these questions. You raise very good points and I hope someone out there can give the answer.

Babs in TX

6/23/03

-37 lbs and counting

[Alexandra 55]

The answer to this question can't be firm, of course, because all insurance carriers and policies are different. But I can tell you the answer *in general.*

If you had a slippage that resulted in a need for medical treatment, yes, treatment would be covered. Each situation is taken on its own--if you have a condition that requires medical treatment you should be able to get it. It doesn't matter if what's causing the problem has always been part of your body or is something you added (tattoo, breast implant, pacemaker, lapband).

The medical team would have to code your treatment correctly so that the insurance carrier sees it in the right way, though. The diagnosis code wouldn't be 278.01 (morbid obesity), it would be something else entirely (whatever the code is for gastric obstruction, I guess).

[Mahoney 1]

Well that is good! Another related scenario ran through my head today. I found a website about a very successful bander needing to have his band temporarily removed due to slippage, and then he had another one put back in a couple of months later (http://www.waynesmith.net/lapband/). I have a feeling that the insurance thing could get tricky at that point if one were already at goal weight. Alexandra - make me feel better again and tell me they would probably cover it!

That being said, after I ran through all of my worst case scenarios (like the one above), and I couldn't be more excited about the band. Now if my insurance plan is as excited, we are in business.

Bob

[Alexandra 55]

Bob, sorry but I can't be optimistic about a situation like Wayne's being covered by insurance. The removal, yes, but not the replacement. At the point where his had to be removed, he was no longer MO (or even obese, I don't think). So no, there could be no medical reason to replace the band. It's not a prosthetic required to live, or even to maintain a certain bodily functionality (like an artificial limb). If you're already at a healthy weight, my feeling is that it would be upon you to stay that way.

If something like that happened while you were still very overweight and actively *in treatment* for your MO, a case could be made that the band would need to be replaced so your treatment could continue. There are never any guarantees, of course.

Good luck with your insurance approval. I'll be waiting to hear what they say!!

[bbrecruiter2000 1]

Alex,

Just playing devils advocate here.... Hypothetically, one could say it is medically necessary to replace the band otherwise the patient would blow up to 400 pounds in two years and die of a heart attack. Especially if the patient had co morbidities prior to banding.

I think that the real trouble would be if you now had a diffferent insurance company other than the one you had when you were banded. The new one would be more difficult than the one who put it there and paid for it!!!!

Either way, if that happened to me, I would jump my now (hopefully skinnier butt) on a plane and go to Mexico and have it replaced!!!!

Babs in TX

6/23/03

-37 lbs and counting

[GeezerSue 7]

I think they would handle any problems related to the band the way they would handle any problems related to any other implanted medical device. The problem that necessitated the device may no longer exist, but the device is there and whatever issues result need to be coded correctly.

I'm thinking of subdermal ports as needed for extended chemo. If after chemo, a patient's no-longer-needed port becomes infected, the insurance company can't just deny treatment based on the fact that s/he no longer needs chemo...right? I think the only iffy-factor would be for bands placed out of country before they were legal here.

And Wayne's band was placed very early on. He was self-pay and went through Inamed to the doctors of his choosing...some of the most experienced doctors in North America. They were not stateside and that's why I got the impression he was a cash patient, with the doctors of his choice...not involving insurance in the U.S.

[Alexandra 55]

Originally posted by bbrecruiter2000

Just playing devils advocate here.... Hypothetically, one could say it is medically necessary to replace the band otherwise the patient would blow up to 400 pounds in two years and die of a heart attack. Especially if the patient had co morbidities prior to banding.

Well, sure, but even a doctor isn't really likely to want to operate on a healthy patient "just in case." Once the patient really did start to gain weight rapidly a doctor might reband, as happened in Wayne's case, but insurance carriers have their guidelines and preventing future possibilities aren't in them.

Personally, if my band slipped when I was at or close to goal I'd first want to see if there were any possible chance that my new behaviors could prevent weight gain before having the band replaced. The less surgery the better, IMO.