Revision from Sleeve to DS

cdixon

Member
Hello everyone. I am 36 and have a BMI of 50. I had the sleeve in 2014 I lost about 115 lbs and have since gained almost all of it back. I am ashamed and embarrassed that I failed with the sleeve but I am ready to fight for my life. I am starting the process to submit for revision from sleeve to ds for the second time. I was denied once before and gave up. I currently do not meet the requirements for insurance even though I am class 3 obese. BP is borderline high and cholesterol is a little high. I'm not on meds for either. I think I may have mild sleep apnea I'm going to ask for a sleep study at next weeks doctor visit. I also have knee complication due to weight. I have severe pain and my orthopedic surgeon says my knees are aged 20 years ahead of time. I feel like DS is the only option for me. I have BCBS of TN and for a second bariatric surgery they require a complication from the original surgery. For the DS they also require a BMI greater than 60. My surgeon has ordered a test to see if by sleeve is abnormally large. I am currently waiting on insurance to approve that test. I came here because I do not have much hope that I will be approved for surgery this time either and I do not know what else to do. I do not have much knowledge of insurance and I HAVE to have this surgery to save my life. I thank you all in advanced for your help. What I have read so far has been very informative. Hopefully I can benefit from this forum. This is my first time using a forum so it is a learning curve for me. Please forgive me if I do not know the proper etiquette.
 
Last edited:

southernlady

Administrator
Staff member
Welcome, cdixon
First, you did NOT FAIL the sleeve. It failed you.

Next, you can fight the BMI requirement. But it’s gonna take work on your part as the ladies who will help you do this for free. They will not do it for you but they will help you help yourself.

DianaCox and Larra
 

DianaCox

Bad Cop
Get a copy of their Evidence of Coverage document from your HR department. It is about 100 pages and is the insurance contract, NOT a summary of benefits.

Who is the surgeon you are working with? Does he do a traditional two anastomoses DS?

The weight requirement is ridiculous and not medically supported. It can usually be overcome. If your current BMI is over 40, you shouldn’t need a separate complication to qualify for a revision.
 

hilary1617

First time at the rodeo.
Hi and welcome cdixon ! You are not alone, the sleeve has failed many patients who really needed malabsorptive element in addition to restriction. You have no reason to be embarrassed. You simply had a surgery that wasn't effective/right for you. All the best on your forward journey!
 

cdixon

Member
Get a copy of their Evidence of Coverage document from your HR department. It is about 100 pages and is the insurance contract, NOT a summary of benefits.

Who is the surgeon you are working with? Does he do a traditional two anastomoses DS?

The weight requirement is ridiculous and not medically supported. It can usually be overcome. If your current BMI is over 40, you shouldn’t need a separate complication to qualify for a revision.
Thank you for your reply.

I am in the process of getting the EOC, not successful yet. No one seems to know what I'm talking about. I'm waiting on call backs.

My surgeon is Dr. Stephen Boyce in Knoxville, TN. As far as I know he does the traditional DS his website calls it Biliopancreatic Diversion with Duodenal switch.
 

cdixon

Member
Get a copy of their Evidence of Coverage document from your HR department. It is about 100 pages and is the insurance contract, NOT a summary of benefits.

Who is the surgeon you are working with? Does he do a traditional two anastomoses DS?

The weight requirement is ridiculous and not medically supported. It can usually be overcome. If your current BMI is over 40, you shouldn’t need a separate complication to qualify for a revision.
Following up on my last post. I have gotten the run around with benefits administration when asking for the EOC. I final was able to speak with someone that seemed like she may know what she is talking about. She thinks the document I am looking for is what they call the Plan Document. I have searched the document regarding bariatrics and it appears to have very little info. This is the link to the Plan Document. https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/spd2019.pdf Would you mind to look at the document and confirm this is what I need? Thanks. :)
 

DianaCox

Bad Cop
The first part of it is the right document. It seems to have very little in the way of information about the bariatric surgery requirements - can you find the bariatric policy?

Regarding appeals:
7.04 Disputed Claim.
To ensure that payment of claims is in accordance with plan provisions and that payment reduction is not the result of errors in claim processing, miscommunication or misinterpretation of policies, the following should be followed when a covered person disagrees with a denial or reduction of benefits.
The health care provider, covered person (or representative), or the committee’s representative should contact the claims administrator to determine why a claim(s) has been reduced or denied. If not a processing error, the claims administrator will explain why the claim reduction or denial occurred. If the claim(s) was incurred with a contracted provider, the claims administrator will explain the “hold harmless” provision of the contract and advise the caller of the patient’s liability for the claim. If the claim(s) was with a non-contracted provider, or if there were both contracted and non-contracted claims, the caller will be advised to write the claims administrator and request a review of the claim(s). The claims administrator will review the written request and respond in writing within 60 calendar days of receipt of the request. After review, if claims are still reduced or denied, a detailed written explanation will be given to the covered person of the reasons for the reduction or denial. At this time, the covered person will be advised of any additional levels of review available to them.
If the dispute regarding the claims cannot be resolved at the claims administrator level, the covered person can initiate an appeal. Such appeal is to be made in accordance with both the policies and the rules and regulations of the committee. The committee is authorized to promulgate such rules and regulations necessary to process appeals.

Ask for the policies and rules and regulations. They may include referring to an outside medical review organization (I’ve had this happen with a self-funded plan) for external medical review, even though the committee makes the ultimate decision.
 

cdixon

Member
The first part of it is the right document. It seems to have very little in the way of information about the bariatric surgery requirements - can you find the bariatric policy?

Regarding appeals:
7.04 Disputed Claim.
To ensure that payment of claims is in accordance with plan provisions and that payment reduction is not the result of errors in claim processing, miscommunication or misinterpretation of policies, the following should be followed when a covered person disagrees with a denial or reduction of benefits.
The health care provider, covered person (or representative), or the committee’s representative should contact the claims administrator to determine why a claim(s) has been reduced or denied. If not a processing error, the claims administrator will explain why the claim reduction or denial occurred. If the claim(s) was incurred with a contracted provider, the claims administrator will explain the “hold harmless” provision of the contract and advise the caller of the patient’s liability for the claim. If the claim(s) was with a non-contracted provider, or if there were both contracted and non-contracted claims, the caller will be advised to write the claims administrator and request a review of the claim(s). The claims administrator will review the written request and respond in writing within 60 calendar days of receipt of the request. After review, if claims are still reduced or denied, a detailed written explanation will be given to the covered person of the reasons for the reduction or denial. At this time, the covered person will be advised of any additional levels of review available to them.
If the dispute regarding the claims cannot be resolved at the claims administrator level, the covered person can initiate an appeal. Such appeal is to be made in accordance with both the policies and the rules and regulations of the committee. The committee is authorized to promulgate such rules and regulations necessary to process appeals.

Ask for the policies and rules and regulations. They may include referring to an outside medical review organization (I’ve had this happen with a self-funded plan) for external medical review, even though the committee makes the ultimate decision.
Ok. I will ask for the rules and regulations policy. I work for the State of Tennessee and was told today that I have a self funded plan.
 

cdixon

Member
The first part of it is the right document. It seems to have very little in the way of information about the bariatric surgery requirements - can you find the bariatric policy?

Regarding appeals:
7.04 Disputed Claim.
To ensure that payment of claims is in accordance with plan provisions and that payment reduction is not the result of errors in claim processing, miscommunication or misinterpretation of policies, the following should be followed when a covered person disagrees with a denial or reduction of benefits.
The health care provider, covered person (or representative), or the committee’s representative should contact the claims administrator to determine why a claim(s) has been reduced or denied. If not a processing error, the claims administrator will explain why the claim reduction or denial occurred. If the claim(s) was incurred with a contracted provider, the claims administrator will explain the “hold harmless” provision of the contract and advise the caller of the patient’s liability for the claim. If the claim(s) was with a non-contracted provider, or if there were both contracted and non-contracted claims, the caller will be advised to write the claims administrator and request a review of the claim(s). The claims administrator will review the written request and respond in writing within 60 calendar days of receipt of the request. After review, if claims are still reduced or denied, a detailed written explanation will be given to the covered person of the reasons for the reduction or denial. At this time, the covered person will be advised of any additional levels of review available to them.
If the dispute regarding the claims cannot be resolved at the claims administrator level, the covered person can initiate an appeal. Such appeal is to be made in accordance with both the policies and the rules and regulations of the committee. The committee is authorized to promulgate such rules and regulations necessary to process appeals.

Ask for the policies and rules and regulations. They may include referring to an outside medical review organization (I’ve had this happen with a self-funded plan) for external medical review, even though the committee makes the ultimate decision.
I asked the question you suggested and received a reply stating that the Information in the BCBS policies are the bariatric surgery requirements. I pulled some info. from BCBS Medical Policy Manual and listed it below. I was also informed that the appeals information in the Plan Document is not specific to bariatric surgery but applies to any adverse determination. I also listed a insert of that Appeals Provision below.

I also called my surgeons office today to see where we stand on getting the test approved to measure my stomach. They stated that they had to submit clinicals and are waiting for a response back.

I can't express enough gratitude for your guidance. Thank you.


MEDICAL APPROPRIATENESS
Bariatric surgery is considered medically appropriate if ANY ONE of the following criteria are met:
An initial bariatric surgical procedure requested and ALL of the following:
Individual is 18 years of age or older
The Bariatric Surgery Precertification Request Form completed and submitted with the request for authorization
Diagnosis of morbid obesity classified as ANY ONE of the following:
Class 3 obesity with a BMI greater than or equal to 40 kg/m2
Class 2 obesity with a BMI 35 to 39.9 kg/m2 with ANY ONE of the following obesity related comorbidities:
Coronary artery disease
Type 2 diabetes mellitus
Obstructive sleep apnea
Hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic)
Absence of ALL of the following excessive risk co-morbidities:
Contraindications to general anesthesia
Uncorrectable coagulopathy
Irreversible cardiopulmonary disorders (e.g. right heart failure, severe pulmonary arterial hypertension, advanced cardiomyopathy)
End-organ failure (e.g. end stage renal disease, candidate for transplant)
Metastatic or inoperable malignancy
Attending physician is someone other than the operating surgeon and his/her associates
Attending physician documents individual is able and willing to be compliant with the necessary post - procedural dietary restrictions
Attending physician documents attempts at a non-surgical weight loss program (e.g. dietary management, behavior modification, and/or exercise) with ALL of the following:
Most recent attempt was within 2 years of request for surgery
Weight has either remained stable or decreased
Non-surgical programs have not achieved desired weight loss
Comprehensive psychosocial - behavioral evaluation with ALL of the following:
Submitted by a clinician whose license authorizes them to conduct psychological evaluations, perform psychotherapy or counseling and administer and interpret psychological tests*
Clinical interview completed no more than one (1) year prior to request for initial surgery
At least one psychological test and/or assessment tool administered and evaluated (Possible choices: Minnesota Multiphasic Personality Inventory®-2, MMPI®-2-Restructured Form, or Millon®
Behavioral Medicine Diagnostic with bariatric norms)
Conclusion that individual is able and willing to comply with requisite dietary and behavioral modifications following surgery
(*NOTE: Currently only Licensed Senior Psychological Examiners (LPSE), Psychologists and Psychiatrists are contracted by BCBST for psychological testing.)
A subsequent bariatric procedure that is a correction (revision), or reversal of the previous bariatric procedure with ALL of the following:
The revision or correction is not an investigational procedure
Physician documented complication related to the original surgery (e.g., fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, or pouch enlargement not due to
overeating)
A subsequent bariatric procedure that is a conversion of a previous bariatric procedure to a different type of bariatric surgery with ALL of the following:
The requested procedure is not an investigational procedure
Individual meets all of the criteria for an initial bariatric procedure (Note: documentation submitted for the initial bariatric surgery does not count toward meeting the criteria for the conversion procedure,
all documentation must be resubmitted)
Request is two (2) years or more since the initial surgery
Weight loss is less than 50% of initial procedure pre-operative excess body weight
Weight remains at least 30% over ideal body weight (using standard tables for adult weight ranges from the National Heart Lung and Blood Institute:

6.05 Appeals Provision.
A covered person may request an appeal of a decision made by the claims administrator relative to the disposition of a claim, the utilization review guidelines, or as determined by Benefits Administration, administrative decisions made on behalf of the plan. The covered person must first exhaust any and all levels of the internal complaint or grievance process available through the claims administrator before initiating an external level of appeal. The covered person should first call the claims administrator at the telephone number listed on his/her insurance card. If the covered person has received correspondence pertaining to an inquiry, the covered person should ask for the correspondent by name to discuss the issue. If the covered person’s complaint cannot be resolved on an informal basis, they may submit a formal complaint in a manner designated by the claims administrator. The claims administrator may require the covered person to complete and file a “member grievance form” or other designated form. Such forms may be obtained by calling the claims administrator at the telephone number listed on the covered person’s insurance card. The complaint or grievance should be filed with the claims administrator within the specified timeframe and will be reviewed by a committee as designated by the claims administrator. Within 60 calendar days of receipt of the written complaint, the claims administrator will issue a written decision to all of the parties involved and will advise them of any further appeal options, including external appeal through an Independent Review Organization (IRO).
 

DianaCox

Bad Cop
OK, but I don’t see why you need to find a reason for a complication - there is a SEPARATE and distinct requirement for conversion to a different procedure:
A subsequent bariatric procedure that is a conversion of a previous bariatric procedure to a different type of bariatric surgery with ALL of the following:
  • The requested procedure is not an investigational procedure YES
  • Individual meets all of the criteria for an initial bariatric procedure (Note: documentation submitted for the initial bariatric surgery does not count toward meeting the criteria for the conversion procedure, YES - and DS doesn’t require BMI >50
  • all documentation must be resubmitted)
  • Request is two (2) years or more since the initial surgery YES, right?
  • Weight loss is less than 50% of initial procedure pre-operative excess body weight YES, right?
  • Weight remains at least 30% over ideal body weight (using standard tables for adult weight ranges from the National Heart Lung and Blood Institute: YES, right?http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm
So it seems to me you have already met all the requirements; you just have to point out the documentation that has already been submitted, or get your doctor to write a letter requesting preauthorization that addresses each requirement, just like above - quoting the policy in bullet points and providing proof that the requirement is met by pointing to facts in your medical records establishing that the requirement is met.
 

cdixon

Member
OK, but I don’t see why you need to find a reason for a complication - there is a SEPARATE and distinct requirement for conversion to a different procedure:
So it seems to me you have already met all the requirements; you just have to point out the documentation that has already been submitted, or get your doctor to write a letter requesting preauthorization that addresses each requirement, just like above - quoting the policy in bullet points and providing proof that the requirement is met by pointing to facts in your medical records establishing that the requirement is met.
Just to clarify I answered the questions below.

  • The requested procedure is not an investigational procedure YES
  • Individual meets all of the criteria for an initial bariatric procedure (Note: documentation submitted for the initial bariatric surgery does not count toward meeting the criteria for the conversion procedure, YES - and DS doesn’t require BMI >50
  • all documentation must be resubmitted)
  • Request is two (2) years or more since the initial surgery YES, right? Correct
  • Weight loss is less than 50% of initial procedure pre-operative excess body weight YES, right? Correct I am above my original surgery weight
  • Weight remains at least 30% over ideal body weight (using standard tables for adult weight ranges from the National Heart Lung and Blood Institute: YES, right? Correct my BMI 51
I do not know what happened. I either pulled the info from the wrong place or it was a bad copy and paste. Because the
BlueCross BlueShield of Tennessee Medical Policy Manual that I was provide states the following about complications. Here is the link to the complete policy. https://www.bcbst.com/MPManual/Bariatric_Surgery.htm Also when I call BCBS they always says that there is a 60 or greater BMI requirement. Which as you mentioned is not stated in the requirements. They say that they go by the medical policy manual but my policy group can also add there own requirements.

I am sorry about the discrepancies in my last post. I am going to double check once I have access to the computer I sent it on to see if it is possible that I was provided some conflicting information. I have just been looking at so much info lately. Thanks again.
  • A subsequent bariatric procedure that is a correction (revision), or reversal of the previous bariatric procedure with ALL of the following:
    • The revision or correction is not an investigational procedure
    • Physician documented complication related to the original surgery (e.g., fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, or pouch enlargement not due to overeating)
  • A subsequent bariatric procedure that is a conversion of a previous bariatric procedure to a different type of bariatric surgery with ALL of the following:
    • The requested procedure is not an investigational procedure
    • Individual meets all of the criteria for an initial bariatric procedure (Note: documentation submitted for the initial bariatric surgery does not count toward meeting the criteria for the conversion procedure, all documentation must be resubmitted)
    • Request is two (2) years or more since the initial surgery
    • Weight loss is less than 50% of initial procedure pre-operative excess body weight
    • Weight remains at least 30% over ideal body weight (using standard tables for adult weight ranges from the National Heart Lung and Blood Institute: http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm)
 

DianaCox

Bad Cop
You are having a CONVERSION to another procedure, not a revision/correction. Different rules. I don’t see anything limiting the DS to BMI > 60, or even 50, and no such policy is medically justified based on evidence-based medicine. The ASMBS has no such recommendation.
 

cdixon

Member
You are having a CONVERSION to another procedure, not a revision/correction. Different rules. I don’t see anything limiting the DS to BMI > 60, or even 50, and no such policy is medically justified based on evidence-based medicine. The ASMBS has no such recommendation.
Ok. Thank you for making that clear! I feel so much better about this. I plan on asking for a sleep study this Thursday at my pcp appointment and then maybe submit after that.
 
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