Insurance denial

[KT in VA]

Hi - I'm new to this forum, posting this here for feedback:

After 4 months of ridiculous back and forth, miscues (on their part), peer to peer reviews with my surgeon, adding documentation, etc., my insurance (BCBS of IL) has now denied my (1st) appeal for band removal/revision to DS surgery. Their primary reason: not medically necessary as my BMI is not 50 or over (it’s 35). The clinical documentation of severe bile and acid reflux and history of bile aspiration while sleeping (due to the band) was not compelling to them apparently.
So l’m contemplating self-pay. But, my very well respected and recognized-expert-at-DS procedure surgeon is wickedly expensive compared to other self pay quotes I’ve seen others post.
All in he is saying total cost for band removal and DS will be somewhere around $40K. I know could save a ton of money if I travel to another doctor…..but I feel so strongly that I want MY surgeon to remove the band bc he’s the one that put it in, a million years ago. And I trust him implicitly. What would y’all do? Should I try to negotiate with him to bring his self-pay price down? He’s trying to convince me to have it done in an outpatient center vs a hospital, bc he says he can get me the best price that way. Thoughts?!?

 

[southernlady]

Welcome KT in VA
Tagging DianaCox and Larra

 

[Larra]

Well, I'm sorry you are in a bind. First, and I say this a bit cautiously, and without knowing who your surgeon is and why you have such trust in him, but I myself would not consider the DS, either primary or even more as a revision, in any outpatient setting. It just isn't outpatient surgery IMHO. Of course every outpatient facility has a backup plan for people who aren't able to go home the same day, which happens occasionally with perfectly reasonable surgeries and excellent surgeons, but then you are back to the huge cost that you are trying to avoid, and maybe more for transport, etc. The cost for the hospital stay is the biggest expense. Now that I think about it, I haven't heard of DS being done as an outpatient procedure before, anywhere. Of course there could be surgeons doing this that I don't know about, but it sure isn't the usual. If it was just removal of the lap band, that would make sense, but the revision doesn't.
Next, why do you have trust in a surgeon who performed a failing operation on you in the past? Maybe it was so long ago that the bariatric surgery community didn't know just how high the complication rate long-term was with lap band, but it's very high, and here you are with a serious complication from the surgery this surgeon did in the past. And frankly, we've known about the misery and failure of the lap band for years now.
So, what are your options?

1. Continue your appeals. Do you have an external appeal option? That's almost certainly your only hope.
2. See if insurance will cover the lap band removal alone and see how you do without it. Just an idea, you might not like it.
3. Go with your surgeon's outpatient proposal and take your chances that this will work out. Maybe he's done this before with success. Ask.
4. Consider another surgeon, possibly in another country. We know who the good ones are to recommend, because you do need to be careful. I would NOT recommend revision from gastric bypass to DS by this route, but ok for lap band to DS.
5. Do nothing and live with what you have - but given what you are living with, I completely understand why you want revision.

 

[Spiky Bugger]

My DS was a band-to-DS surgery, 17 years ago. I have “followed” postings about DS surgery for maybe 20+ years. I have NEVER heard of anyone who had the DS, let alone a revision, in an outpatient surgery setting.

As far as I know, Elariny is the only “very well respected and recognized-expert-at-DS“ in VA. And he IS very experienced. But if he wants patients to have a DS in an outpatient setting, I’d guess his cognitive processing has gone walkabout. The most polite way I can figure to comment on this, is that there is no way in hell I would trust a doctor who came up with THAT insane suggestion.

I’ve had some of those same negative results from the band, so I strongly suggest having it removed, asap. And then let your body recover. I don’t think I’d consider the DS (for ME) with a BMI of only 35. I know it feels huge to you, but it may not be a weight that needs that big an intervention. (Or, with the band out, you may gain like crazy and “requalify“ for bariatric surgery. Who knows?)

BUT…I think your big problem is NOT insurance denial. Rather, I see it as TWO issues that may be more easily solved in two parts.

Part 1–Get the damned band out because of the problems it is causing. Worth a battle w/insurance company.
Part 2–A year from now, IF your weight is high enough (for you) to think a DS will be worth the various changes to your life, I think you can prevail in a battle with your insurance company. That BMI of 50 is arbitrary and ridiculous.
Part No Number—band removal in an outpatient setting…probably okay. DS surgery in a real hospital, with real, live, well-trained staff to assist you for a few days post-op…mandatory

Sorry you asked?

 

[JackieOnLine]

out patient for a revision?!

 

[DianaCox]

I would not want a LapBand surgeon - who put a worthless piece of crap in me, especially within the last 10 years, knowing it’s high failure rate - to touch me again.

Elariny (if that’s who it was) is a good surgeon, but his business practices make me twitch. Enough said.