adshabrack

Insurance denial for revision from lapband to sleeve

6 posts in this topic

I have been fighting my insurance company for 3 months now over my revision. I had lapband in 2008, and lost 80lbs in 6 months. However, my weight loss stopped there, and I have regained 40lbs (which fluctuates), and my surgeon recommended having a revision. My endocrinologist also recommended it since the initial surgery was done to alleviate issues/complications with my type 2 diabetes, for which I am now taking 5 medications for, including a TON of insulin each day.  The insurance is saying that since there is no device failure, then they should not have to approve an additional procedure and that it's not medically necessary.  However, their definition of medically necessary is to improve or treat a disease that affects the overall health and life span of the patient.  I also have developed sleep apnea and arthritis in my knees since the first surgery. I have appealed twice, and they are still saying no.  What can I do to convince them that this is medically necessary???

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As an attorney, my instinct is to tell you to consult with an attorney and to have that person send the insurance company a nasty letter demanding coverage for your surgery.  

Aussie H and adshabrack like this

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Do you pray? If so, I highly recommend it. Prayer moves mountains.  That and whatever you can through legal channels.

Wishing you the best. Please keep us posted.

Edited by ShrinkingViolet2
Molinam likes this

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If there is nothing wrong with your lap band then why (other than money) does your surgeon think it should be revised. You've lost weight with it before, so even if you can't get a revision, it should still work albeit not as effectively as other surgeries, and certainly not as efficiently as it would have when it was first placed. My original surgery is totally stuffed but I can still lose weight much easier than I could prior to having it over 30 years ago. I would seriously suggest that for now at least, while you are launching your legal battle, that you get good advice on how to use the band that you already have in place if for no other reason than your own health sake. I'm not wishing to sound harsh, but I'm sure it comes across that way, but weight regain wouldn't get you much sympathy with any bean counting insurers. I suspect you're in for a lengthy battle.

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Aussie H  -  That's like saying, "Have you tried Weight Watchers?"  I have done EVERYTHING correctly. The lapband accounts for only 5% of the surgeries done here in the US now. When I had it done in 2008, it was 54%.  Almost half of the patients who have had the lapband have it removed within 5 years or have it revised. It's simple. The procedure does not work for many people. My physician does not offer it as an option anymore in her practice. I am glad it works for you, but it did not for me. 

 In my case, it is not helping my diabetes, even at the tightest setting. I need a more restrictive procedure, and the gastric sleeve and bypass have shown to dramatically reduce the effects of diabetes, or even send it into remission. As far as I am concerned, and my physicians as well, this is medically necessary.  If I do not have this done, my health will continue to decline. 

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12 minutes ago, adshabrack said:

Aussie H  -  That's like saying, "Have you tried Weight Watchers?"  I have done EVERYTHING correctly. The lapband accounts for only 5% of the surgeries done here in the US now. When I had it done in 2008, it was 54%.  Almost half of the patients who have had the lapband have it removed within 5 years or have it revised. It's simple. The procedure does not work for many people. My physician does not offer it as an option anymore in her practice. I am glad it works for you, but it did not for me. 

 In my case, it is not helping my diabetes, even at the tightest setting. I need a more restrictive procedure, and the gastric sleeve and bypass have shown to dramatically reduce the effects of diabetes, or even send it into remission. As far as I am concerned, and my physicians as well, this is medically necessary.  If I do not have this done, my health will continue to decline. 

As i said I didn't want what I said to come across harshly, but knew you'd likely take it that way. However I do think you'll have a huge battle on your hands, and I can see why the insurance bean counters would fight you all the way. That said you do still have a working pouch that you can use. I actually don't and just to be clear do not have, nor ever would have, a lapband. Yes I'm having a revision, fully funded what's more. My "medical necessity" was that my staples eroded through my stomach muscle after 30 years of being there. Pardon me for knowing the difference between revision for medical necessity, and revision for regain. I hope you get your surgery approved, in the meantime use your pouch to its best advantage....you might just be surprised by what it is still capable of.

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