I assume this is your bariatric policy:
http://medpolicy.amerihealth.com/po...f3!OpenDocument&Highlight=0,bariatric,surgery
Do you have:
- A BMI between 35 and 40 in conjunction with one or more comorbidities related to obesity (e.g., refractory hypertension, coronary artery disease, type 2 diabetes mellitus, clinically significant obstructive sleep apnea, pseudotumor cerebri, severe nonalcoholic steatohepatitis [NASH])
or any other severe comorbidity? I'm guessing your sleep apnea is being treated?
Note: this does NOT apply to you:
Sleeve Gastrectomy as Part of a Two-Staged Procedure
Sleeve gastrectomy performed as part of a two-staged procedure is considered one
surgery for the purposes of the Company's
bariatric surgery benefit.
As a risk reduction strategy for individuals who are morbidly obese, sleeve gastrectomy (laparoscopic [CPT code 43775] or open [CPT code 43843]) as part of two-stage procedure is considered medically necessary and, therefore, covered for individuals who are 18 years of age or older when
all of the following criteria are met:
- The individual has a BMI greater than or equal to 50.
In other words, the two-stage DS procedure is what is limited to having a starting BMI >50. Not a virgin DS or a revision from what was originally intended to be a definitive sleeve.
This is the revision/conversion part:
SECOND
BARIATRIC SURGICAL PROCEDURES
If it is NOT specifically excluded under the terms of the member's benefit contract, the following are considered medically necessary for members
who met medical necessity criteria for their initial bariatric surgery:
- Conversion (e.g., to a Roux-en-Y gastric bypass or vertical gastrectomy) for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and who have been compliant with a prescribed nutrition and exercise program following the initial procedure (documented in the letter of medical necessity). In addition, the member must have been examined by a licensed mental health professional provider that specifically evaluates all of the following: any mental health or substance abuse conditions; the emotional readiness and ability of the individual to make and sustain lifestyle changes; and the adequacy of the individual's support system.
- Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch where the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the initial procedure (documented in the letter of medical necessity)
- Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments
- The second stage of a covered two-stage procedure (sleeve gastrectomy and duodenal switch; sleeve gastrectomy and gastric bypass) [this doesn't apply to you]
You could argue either conversion or revision - it is arguably a revision, since the sleeve has dilated and needs to be revised, with a switch added for metabolic effect.
And here is where the real concern is - you need to find out what YOUR plan is - what does your "member benefit contract" (or EoC) say??:
SECOND
BARIATRIC SURGICAL PROCEDURES
Member benefit contracts may limit bariatric surgery to one surgical procedure per lifetime.
A prior
bariatric surgery can be counted towards the lifetime limit under the following circumstances:
- Fully insured groups: the member is employed by the same employer and the same Carrier provides coverage (e.g., the member was employed by Employer ‘A’ at the time of the first surgery, which was covered by the Company. At the time of the request for the second surgery, the member is still employed by ‘A’ and the Company is still the Carrier). Please note that if the employer group changes Carriers, any surgery performed while the employed was covered by the earlier Carrier will not be counted toward the lifetime limit.
- Self-insured groups: the member is covered under the same group Health Plan (i.e. employer), but the employer changes claims administrators (e.g., the member was employed by Employer ‘A’ at the time of the first surgery and the Claims Administrator was not the Company. At the time of the request for the second surgery, the member is still employed by ‘A,’ but the Company is now the Claims Administrator).
- The employer changes its funding status (e.g., the member was employed by Employer ‘A,’ which was fully insured at the time of the first surgery. At the time of the request for the second surgery, the member is still employed by ‘A,’ but ‘A’ has changed its funding status to self-insured).
- The member changes products (i.e., the member was employed by Employer ‘A’ and enrolled in a Company HMO program at the time of the first surgery. At the time of the request for the second surgery, the member is still employed by ‘A,’ but is now enrolled in a Company PPO program).
Any new or different obesity
surgery, revisions, repeat, or reversal of any previous
surgery may not be covered even if the new or different procedure intended to treat obesity is medically necessary.
The limitation of coverage for a repeat, reversal, or revision of a previous obesity surgery does not apply when the initial procedure results in technical failure or when the proposed procedure is required to treat complications of the initial procedure, which if left untreated, would result in endangering the health of the individual. [I DON'T THINK YOU MEET THIS EXCLUSION OF THE EXCLUSION - it DOES apply to you]
Weight gain or weight plateau resulting from
failure to follow the regimen of diet and exercise recommended after the first bariatric surgery would be excluded from coverage for a repeat, reversal, or revision of a previous obesity surgery because the second procedure is not being performed to treat a complication or technical failure of the initial procedure.
You need to start gathering evidence that you followed the regimen of diet and exercise recommended after the first bariatric surgery. Get a copy of your medical records, evidence that you joined a gym and attended, whatever you have. 
