adshabrack

Insurance denial for revision from lapband to sleeve

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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.  

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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

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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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 I just have to ask. The band only holds so much fluid  and when it is full but you are gaining weight, what do you do then? If you have diabetes, high blood pressure, or other co-morbities, what then?? Just curious about this.

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12 hours ago, Brenda B. said:

 I just have to ask. The band only holds so much fluid  and when it is full but you are gaining weight, what do you do then? If you have diabetes, high blood pressure, or other co-morbities, what then?? Just curious about this.

It's been close to 2 years since this thread was started Brenda and the OP hasn't been back since.

Sadly, regardless of what bariatric surgery we choose, if we don't follow the guidelines on food choices and portion control, surgery will be a waste of everyone's time (and money).

I personally know of one woman who had the gastric band.  From the day she got home from surgery she has ignored all the guidelines - especially when she realised that you can put pretty much anything in a blender (think candy bars, cake and icecream) and without the issues of fat and sugar intolerances that comes with a gastric bypass and to a lesser degree with the VSG, there was nothing to prevent her from piling the pounds on and I'm guessing that she's close to 100 lb heavier that when she started out.  She had one follow-up with her surgeon and never went back.

She had comorbidities going into surgery ... she has more now.

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7 hours ago, cinwa said:

It's been close to 2 years since this thread was started Brenda and the OP hasn't been back since.

Sadly, regardless of what bariatric surgery we choose, if we don't follow the guidelines on food choices and portion control, surgery will be a waste of everyone's time (and money).

I personally know of one woman who had the gastric band.  From the day she got home from surgery she has ignored all the guidelines - especially when she realised that you can put pretty much anything in a blender (think candy bars, cake and icecream) and without the issues of fat and sugar intolerances that comes with a gastric bypass and to a lesser degree with the VSG, there was nothing to prevent her from piling the pounds on and I'm guessing that she's close to 100 lb heavier that when she started out.  She had one follow-up with her surgeon and never went back.

She had comorbidities going into surgery ... she has more now.

Thank you for replying. I appreciate the info.

 

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20 hours ago, cinwa said:

It's been close to 2 years since this thread was started Brenda and the OP hasn't been back since.

Sadly, regardless of what bariatric surgery we choose, if we don't follow the guidelines on food choices and portion control, surgery will be a waste of everyone's time (and money).

I personally know of one woman who had the gastric band.  From the day she got home from surgery she has ignored all the guidelines - especially when she realised that you can put pretty much anything in a blender (think candy bars, cake and icecream) and without the issues of fat and sugar intolerances that comes with a gastric bypass and to a lesser degree with the VSG, there was nothing to prevent her from piling the pounds on and I'm guessing that she's close to 100 lb heavier that when she started out.  She had one follow-up with her surgeon and never went back.

She had comorbidities going into surgery ... she has more now.

My sister has lost nothing with her band since surgery day. The only weight she lost was on her pre-op diet. Fortunately for her she hasn't gained and seemed content that at least her yo-yo lifestyle had stopped. That was until I had my revision and reached goal. Then her son in law had a bypass and has lost loads of weight (his starting BMI I would guess was well into the 60s if not 70s). She never changed her diet much other than avoiding the foods that tend to get stuck. Ice cream, chocolates,  pasta etc are all very much staples in her diet....along with copious amounts of alcohol....and I'm talking everyday drinking here. I'm trying to be positive about her revision, but it's really difficult at times knowing she didn't make the necessary dietary changes when she had her band and I very much doubt that will change this time around either. I hope she does but I can't/won't be nagging her in that regard.

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2 hours ago, Aussie Bear said:

My sister has lost nothing with her band since surgery day. The only weight she lost was on her pre-op diet. Fortunately for her she hasn't gained and seemed content that at least her yo-yo lifestyle had stopped. That was until I had my revision and reached goal. Then her son in law had a bypass and has lost loads of weight (his starting BMI I would guess was well into the 60s if not 70s). She never changed her diet much other than avoiding the foods that tend to get stuck. Ice cream, chocolates,  pasta etc are all very much staples in her diet....along with copious amounts of alcohol....and I'm talking everyday drinking here. I'm trying to be positive about her revision, but it's really difficult at times knowing she didn't make the necessary dietary changes when she had her band and I very much doubt that will change this time around either. I hope she does but I can't/won't be nagging her in that regard.

That is a sad story AB - it must be difficult for you to see your sister on such a life threatening downward spiral.

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14 hours ago, cinwa said:

That is a sad story AB - it must be difficult for you to see your sister on such a life threatening downward spiral.

It's more frustrating than anything. She stays at my place a lot, and sees how it eat/drink is vastly different to the way she does. I get the impression that she still believes that it is the surgery that does all the work despite what I tell her, and what she should be seeing with her own eyes. It really makes me feel like she is selling my efforts short!  She's definitely not a dumb person by any stretch, but does seem to have bought into the "easy way out" hype.

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8 hours ago, Aussie Bear said:

It's more frustrating than anything. She stays at my place a lot, and sees how it eat/drink is vastly different to the way she does. I get the impression that she still believes that it is the surgery that does all the work despite what I tell her, and what she should be seeing with her own eyes. It really makes me feel like she is selling my efforts short!  She's definitely not a dumb person by any stretch, but does seem to have bought into the "easy way out" hype.

Easy way out or not, I can only assume she has blinkers on .... no one can argue with the results from your revision.  Regardless of how you achieved it, a 50 kg (110.2 lb) loss is a success. 

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11 hours ago, Aussie Bear said:

It's more frustrating than anything. She stays at my place a lot, and sees how it eat/drink is vastly different to the way she does. I get the impression that she still believes that it is the surgery that does all the work despite what I tell her, and what she should be seeing with her own eyes. It really makes me feel like she is selling my efforts short!  She's definitely not a dumb person by any stretch, but does seem to have bought into the "easy way out" hype.

@Aussie Bear Sorry to hear of this. To all of you lurkers out there trying to decide if surgery is the way to go, a couple of things:

- Surgery gives you a pouch that is small and when full, you don't feel hungry --> so you lose weight. Surgery does NOT alter the attitudes and habits and thinking of the person having the surgery. If you ate Twinkies 18 hours a day before surgery and think surgery will magically prevent you from buying and eating Twinkies, think again. You have to quit buying Twinkies too. 

You can defeat the pouch benefits by eating all the time for emotional reasons. Success does not require perfect adherence to the WLS diet, but it does require SOME mindfulness and reasonable choices. One of the reasons why WLS usually requires a psychological evaluation is so that people who are NOT committed to stopping their Twinkie habit are flagged and can get psychological attention and help with this form of emotional eating. 

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5 hours ago, BurgundyBoy said:

To all of you lurkers out there trying to decide if surgery is the way to go, a couple of things:

- Surgery gives you a pouch that is small and when full, you don't feel hungry --> so you lose weight. Surgery does NOT alter the attitudes and habits and thinking of the person having the surgery. If you ate Twinkies 18 hours a day before surgery and think surgery will magically prevent you from buying and eating Twinkies, think again. You have to quit buying Twinkies too. 

You can defeat the pouch benefits by eating all the time for emotional reasons. Success does not require perfect adherence to the WLS diet, but it does require SOME mindfulness and reasonable choices. One of the reasons why WLS usually requires a psychological evaluation is so that people who are NOT committed to stopping their Twinkie habit are flagged and can get psychological attention and help with this form of emotional eating. 

As usual, I totally agree on this with @BurgundyBoy

I also believe that the limited diet and lack of hunger in the first few months after weight loss surgery makes it much easier to retrain yourself to eat "mindfully" - in other words thinking about what you are eating and making intelligent decision on what to eat. 

Thus, while weight loss surgery will not resolve overeating issues that have deep seated emotional or historical reasons which require therapy to resolve (such as being a victim of abuse) - weight loss surgery should make it easier for most people to transition to the mindful and more healthy diet necessary to lose excess weight and (even more importantly) keep the weight off in the long term.

As an aside, now that I am at maintenance I can eat almost any food in moderation as part of an overall healthy diet.  I absolutely do not miss the huge portions of unhealthy food that I used to eat.

 

17 hours ago, Aussie Bear said:

It's more frustrating than anything. She stays at my place a lot, and sees how it eat/drink is vastly different to the way she does. I get the impression that she still believes that it is the surgery that does all the work despite what I tell her, and what she should be seeing with her own eyes. It really makes me feel like she is selling my efforts short!  She's definitely not a dumb person by any stretch, but does seem to have bought into the "easy way out" hype.

I totally agree (as usual) with @Aussie Bear that weight loss surgery is not the "easy way out" in that weight loss success (especially in the long term) requires a change in both lifestyle and diet.  That having been said, the surgery does make it easier to make this change. 

In any case, even if weight loss surgery was the easy way out, so what?  What is wrong with using a medical procedure or treatment to resolve a serious medical problem?  A cast is the "easy way out" for fixing a broken leg, surgery is the "easy way out" for resolving the risk of an inflamed appendix, and antibiotics are the "easy way out" to resolve pneumonia, and yet no one believes that these "easy ways out" are not the smart and proper options to take.  If a person has a long history of being seriously overweight, and normal diet regimes have not long term resolved this excess weight problem, then weight loss surgery is an appropriate medical option.

Finally, anyone who knows @Aussie Bear's medical history with weight loss surgeries will understand that her weight loss surgery history has hardly been an "easy" path.  Her ability to keep on going through multiple surgeries and nasty side effects, and to keep her excess weight off, is an inspiration to us all.

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