Lightweight Sleeved Revision to DS - HELP

[Sleeved2013]

Hi I'm new to the group. I was a sleeved (self-pay) in Mexico in March 2013 I lost 60% of my access weight (234 to 165) and kept it off until May 2016. I have been regaining weight even though I am meal prepping and exercising 4-5 days per week. I am currently 205lbs 5'3" 1/2 with high blood pressure and Type 2 diabetes (my doctor gave me 6 months to get it under control with vitamins before prescribing Metformin).
I live in Southern Ohio and looking for a surgeon. I am willing to travel and I have insurances that cover weight loss surgery (Anthem BC/BS as primary and Medical Mutual as secondary).
Any suggestions for surgeons that do revisions on lightweights?
Any advice for insurance approval?

 

[Mermaid]

I'm new here, so I don't know anything about surgeons in your area, but here is anthem's medical policy for bariatric surgery.
https://www.anthem.com/medicalpolicies/policies/mp_pw_a053317.htm

I'm a revision-in-waiting and the sticking point for my Anthem is the 6 month diet and how my doctor didn't document it sufficiently. My nutritionist documented it perfectly, but Anthem wanted a cover letter/detailed summary from my surgeon. It's an ongoing battle.

Get a folder and start documenting everything. Right from the beginning: calls to insurance, your policy coverage document, office visit notes, medical history, surgical records from your sleeve, food logs...everything. You may or may not need them but it's good to have them if you do.

 

[Larra]

Hi and welcome!
Almost all DS surgeons will do VSG to DS revisions, since the sleeve is part of the DS and they just need to add the "switch" part (unless you need a resleeve). Hopefully someone will come along with options near Ohio, as my mind is blanking at the moment.
There are many different insurance policies, so just knowing you have Anthem is not enough. You need to get your EOC (Evidence of Coverage), which is a LONG document, not just a summary of benefits, to see what is covered and what criteria you need to meet. Keep in mind that requirements for revision are often different from those for a virgin bariatric surgery, and also that some policies have "one operation per lifetime" clauses such that no revisions are covered even in the face of medical necessity. I hope your policy doesn't have this! My personal belief is that this shouldn't be legal, but apparently it is.
I calculated your bmi with a height of 5'3" and it came to 36.3, which with your type 2 diabetes should give you grounds for medical necessity. I know we all have years of experience of considering ourselves as tall as possible, but this is the time to round down and be short.

Lastly, please don't feel like a failure. It is the operation that failed, not you. Sleeve as a stand alone has no metabolic benefits, just restriction, which in effect is like a permanent diet whether you continue to experience restriction or not. Almost all of us have experience with dieting and exercising our hearts out yet losing very slowly, if at all. If your metabolism is broken, a sleeve won't fix it, but a DS will.

 

[Sleeved2013]

@Mermaid Thank you for this information!

I earlier this year I went to a doctor supervised WL for Adiphex and they gave me kidney stones so I stopped taking them after several months. Hopefully if I find the right surgeon the approval process will not take long.

 

[Sleeved2013]

@Larra Thank you for this information.

I will get the EOC from both my insurances when I'm back at work next week. My Anthem insurance does have the "one operation per lifetime" I think but since my 1st surgery I paid myself before I had insurance coverage in Mexico hopefully I can get it covered. My secondary insurance also covers WLS. I am not sure of the details yet. Hopefully once I get the EOC I can get some help with understanding my battle.

If all else fails and I have to self pay again I am willing to return to Mexico or another country to have the surgery.

It is good to know about the height situation, since I normally put on everything I am 5'4". For this I will put I am 5'3".
Thank you for the word on encouragement. I have been feeling like a failure (broken) and not understanding why I have gained weight even after surgery. It wasn't until I got on this site (I have literally read every post since Nov. going back several years before) and started reading about the sleeve that I determined I have options and the best option is DS. I just felt comfortable enough to signup on this site with a login and post questions.

 

[Larra]

I hate to be the bearer of potentially bad news, but many of these "one operation per lifetime" policies won't pay for a revision even if you paid for the first operation. And I don't know how it works if you have 2 policies - @DianaCox probably understands this best.
If you do need to self-pay, the only surgeon in Mexico recommended around here is Dr. Esquerra. There are a lot of people here who have had their DS with him, and everyone seems to be very pleased both with him and also with the quality of care at the hospital there. So if insurance doesn't work, you do have a good alternative.

 

[Sleeved2013]

@Larra and @DianaCox
I was able to access my EOC online when I logged into Anthem and its the same document that Mermaid provided. If this is the correct EOC then it does not mention anything regarding "one operation per lifetime" this this exciting. Let me know if I would request a copy from my HR or Anthem directly.
Thank you for the surgeon name in Mexico I will keep his name in my back pocket as a backup.
I'm not able to copy and paste the link from Mermaid's earlier response.

 

[Mermaid]

@Sleeved2013 i posted the Bariatric Policy for Anthem, this is not your EOC. Surg.00024 is the general guidelines Anthem sets for Bariatric Surgery. Your EOC will show what you're employer chooses to have coverage for.

Your evidence of coverage will be 80+ pages and you usually need to get it from your employer (or try googling "company name, anthem, evidence of coverage"). I found my EOC by doing this, but still had to verify with my employer that it was the most up to date document.
The EOC covers all the nuances of your exact policy. Not exactly summer beach reading, but definitely informative.

 

[Mermaid]

Here is an example of an EOC I found online. This is not your document. They are very specific to each policy.
https://www.calpers.ca.gov/docs/2016-anthem-traditional-hmo-evidence-coverage.pdf

 

[southernlady]

Welcome, @Sleeved2013

 

[Larra]

What @Mermaid said, and contact HR for yours. Don't be shocked if they don't know what you're talking about. Request to speak with a supervisor or manager if necessary.

 

[Clematis]

The good news is, all you need is the switch part which should be an easy surgery for you, recovery wise.

Yes be sure and get YOUR Evidence of Coverage. "Anthem in Ohio" can mean countless types of policies. Last year my husband's company in Ohio offered three types of Anthem policies, all at the same time: one covered NO WLS, another did cover it and the third covered it but with prohibitive restrictions. (At the time of my surgery, we were in the no WLS type. In hindsight, being compelled to self pay for Esquerra in MX was a very good thing -- no insurance roadblocks to leap over, surgery scheduled in a month, four day hospital stay. Truly excellent care.)

My husband's company did not have copies of the EOC and I had to call Anthem. Here's the tricky thing when calling Anthem to get the booklet: although I can't find my EOC, I seem to recall that it wasn't called "Evidence of Coverage" but something else. Furthermore the title on the front cover was different than the title on the first page!! (I have posted the titles for someone on BF but I can't find that post either. Sorry.)

BTW the links on My Anthem only show a summary, not the EOC. I called Anthem and they did send it.

Ohio surgeons are few and do not seem to have a lot of experience doing the DS. I found a doc in Dayton and another outside of Toledo who advertise the DS. (None in Cinci or Columbus). The Cleveland Clinic supposedly does them but they don;t have much experience and only do them on SMO (BMI 50+) so I doubt they will take you. (They also give abysmal nutrition advice.) University Hospitals in Cleveland has recently started advertising the DS (so low experience) but I do not know anyone who has used them.

Good luck

 

[aaa]

Hello.

 

[Clematis]

Found it.

Anthem calls it "Your Health Certificate"

 

[Sleeved2013]

Thank you everyone for your advice.

I will get the full EOC from my HR or Anthem.

I was only able to find a summary on The Kroger Co. employee website. WLS and revisions are covered but have to be at a COE facility, and get a best doctors 2nd opinion (if I do not get the 2nd opinion then an additional $300 will not be covered). Good news is if the COE facility is over 100 miles from me Kroger will pay for travel for me and one person if having surgery in a tier 1 facility. The plan will cover 80%.