Seeking revision from band to sleeve... BCBS FED

[VDLT]

Cross post from the Say Hello forum (it was suggested I post here)

Hello all. My name is Veronica. I am 42 years old and have been banded (self pay) since 2001. I initially did really well with it and lost around 50 pounds. I am 4'11" on a good day and got down to around 145 which was great. I had plastics and my surgeon required me to get unfilled. That started a not so great series of tight fills and unfills. I developed rather severe left shoulder pain around that time and found in the board I used to belong to, that other people were experiencing the same thing. The surgeons I was seeing (not my original doctor since I had moved) did not take this seriously and told me this was in no way band related despite my providing them with numerous accounts of such.
I also developed a hernia, gastritis, and esophagitis. I struggled with the band (love that you call it the crapband) and had a hard time eating anything but crap for years. I vomitted more than I care to admit and finally two years ago I had enough and had it emptied. I feel better but not great and still get symptoms. I have developed a nasty adversion to drinking water as it is usually what makes my shoulder hurt, particularly if I drink too close to a meal (I do not drink with meals). I know I am dehydrated and tired. I have gained all my weight back and no longer participate in activities I did after my initial weight loss. I miss being smaller and feeling better about myself. I miss dancing which I no longer do because I am not comfortable with my appearance and because I have a hard time keeping up.
I went back to my original surgeon and he has recommended a conversion to sleeve. I am a bit under the 40 BMI but submitting to my insurance (BCBS FED) regardless in the hopes that they will cover my revision. I have gather some information stating I have been over 35 BMI for two years, imaging studies from 2011 refecting my gastritis, esophagitis, and hernia. My surgeon's office wants me to get a psych eval. I am worried that if I submit the psych eval they will also request a nutritionist. I am out of town from my surgeon and feel I have hit a wall and just want to do this sooner than later. I have discussed self pay with my surgeon but am concerned that should I develop any complications the insurance will not cover them (my surgeon does not offer BLIS).
Anywho... that is my story. I am looking forward to getting to know you guys and reading the forums here. I appreciate any information you may provide me.

 

[DianaCox]

Without a serious comorbidity, you're going to have trouble getting approved for a revision. You said you have regained all your weight, but that your BMI is <40 - did your self-pay crapband get implanted when you didn't qualify for bariatric surgery in the first place? In which case, we are going to be concerned on several levels.

A little tough talk (in particular because you are not going to get this as soon as you want no matter what):

• "I miss being smaller and feeling better about myself. I miss dancing which I no longer do because I am not comfortable with my appearance and because I have a hard time keeping up."
  • This is NOT a reason for getting a revision, which is serious surgery.
• "I struggled with the band (love that you call it the crapband) and had a hard time eating anything but crap for years. I vomitted more than I care to admit and finally two years ago I had enough and had it emptied. I feel better but not great and still get symptoms."
  • I know it's not easy, but you can't abdicate your responsibility because "you have a hard time eating anything but crap" - that's simply not an acceptable excuse.
• "I have developed a nasty adversion to drinking water as it is usually what makes my shoulder hurt, particularly if I drink too close to a meal (I do not drink with meals). I know I am dehydrated and tired."
  • This is a problem that you need to overcome NOW - not drinking sufficient fluids (at least a half gallon a day) is simply NOT an option - you need to fix this NOW.
• "My surgeon's office wants me to get a psych eval. I am worried that if I submit the psych eval they will also request a nutritionist."
  • And why, exactly, would you (1) worry that the psych eval would necessarily result in a requirement that you see a nutritionist; (2) not WANT a consult with a nutritionist; or (3) not EXPECT that a request for a revision would NOT require a consult with a nutritionist (or even a likely six month medically supervised diet)? It sounds to me that you either have an eating disorder you are trying to avoid confronting, or just plain are non-compliant.
• "I am out of town from my surgeon and feel I have hit a wall and just want to do this sooner than later."
  • Well, guess what? If you want it covered by insurance, it is GOING to be later, unless you develop a life-threatening complication, or don't care whether you get the band explanted without having a revision bariatric surgery. I doubt if you will qualify for revision surgery, and unless you've been diagnosed with Barrett's esophagitis, I'm not sure that insurance is even going to cover removing the band, with the symptoms you've described - they are going to claim you are non-compliant. If you want a revision to another surgery sooner, you're going to have to self-pay, because you don't meet the qualifications for revision surgery.

I'm sorry you made a mistake of having a crapband put in when you didn't medically qualify for bariatric surgery in the first place. I understand that you are unhappy with the regain and the discomfort caused by making that mistake in the first place, but you are in a situation that we warn people about - you hate what you have, it didn't work, but you STILL don't qualify for bariatric surgery - you don't have comorbidities that qualify you, and you just aren't fat enough - you are NOT morbidly obese (yet).

If I were in your shoes I would do one of the following:

• See if I could get the band explanted paid by insurance, by complaining bitterly about the gastritis and vomiting (and after proving that PPIs don't help)
• If that doesn't work, self-pay with another surgeon who offers the self-pay complication coverage, to get that piece of crap out of you, and then wait until your BMI goes over 40 (and it will). Then, IF you don't have insurance with a one-bariatric-surgery-per-lifetime exclusion, maybe they will allow you to be revised to some other procedure.
• In the meantime, I suggest getting off your pity pot and start eating and drinking correctly, and stop using your "missing being smaller and feeling better about myself" as an excuse to feel sorry for yourself; stop your stinkin' thinkin' which allows you to make such pitiful comments as "I miss dancing which I no longer do because I am not comfortable with my appearance and because I have a hard time keeping up." There are people here who END UP YOUR SIZE after bariatric surgery, and they dance and hike and enjoy life - it's on YOU to do that no matter what.

Sorry if this was not what you wanted to hear, but I'm the chief "Bad Cop" and Dispenser of Candor around here, and I think you need truth and not coddling. You are short, yes, but only 50 lbs overweight, and you simply don't qualify for bariatric surgery at this point. It is what it is - it's up to you to make the best of things, and stop making excuses for non-compliance and your own unhappiness.

 

[VDLT]

@DianaCox Thank you for taking the time to respond to my post. I see you wear that "bad cop" hat quite well!

I was self pay for the band. My parents helped me pay for it. My highest weight was 212 but I was around 196 when I got banded which is just below 40 BMI at 39.58 if I am 4'11" . I did not have insurance at the time having just come out of law school and hence the self pay and flexibility with the BMI. So maybe I did not technically meet the requirement for bariatric surgery the day I got on the table but both my surgeon and I felt I was a good candidate due to my history of obesity, high cholesterol, and my family history of obesity, hypertension, high cholesterol, and diabetes.

I would like to address some of the points you made. I make no excuses but would like to explain my position a little further...

I understand that wanting to be smaller alone is not a reason for revision surgery. I know it is serious surgery, believe me it is not an easy decision for me to make to have surgery. When I say I miss being smaller I am not just talking about the cosmetic aspect of being smaller. I mean I miss being able to get out of the car easily, going on scenic walks or museum trips with friends, and overall having a more active and therefore healthier lifestyle. I get winded and tired and am unable to keep up. To me those are valid reasons to want to be smaller. Maybe you will tell me if you believe otherwise and please know I am not opposed to hearing opinions!

I am working diligently on adding water. I make sure I have 20 ozs in the morning with my thyroid medication (I have a 20 oz refillable bottle), and at least another 3 bottles during the day which puts me at a total of 80. I admit I struggle. I hate doing it but I am doing it even though it hurts. I hear you loud and clear that I need to keep pushing this.

As for the psych evaluation and the nutrisionist requirements. My understanding is that these are not always required in medical necessity cases. I do not know if my case qualifies for medical necessity. Can you shed some light on this? I have not been at a BMI of 40 for two years but I have had a 35 BMI for the past two years. My understanding from reading my policy is that a BMI of 35 or over with two comorbidities qualifies.

So my questions are:
Is a 35 BMI not considered morbid obesity?
Are my hiatal hernia, gastritis, esophagitis, high cholesterol (it has returned), thyroid condition, and shoulder pain from drinking and eating not considered comorbidities?
How do I not meet the requirements for revision surgery? Is it because my complications from the band are not "severe"?


Back to the psych eval and nutrisionist. I am not concerned that the psych eval will result in a referral to a nutrisionist. I was just wondering if that would takemy request for approval out of the medical necessity category and place me into the lack of weight loss category of insurance coverage. Again, I don't really know so I am asking

Do I want this sooner than later? Well, yes. I want the band out. I am concerned of the damage it might have done in the past 14 years. I naively thought that since I followed my plan and never had it slip before it would not be causing damage. The imaging studies have proven otherwise. My port also hurts so yes I would like to resolve the matter. Would I want to have a different procedure in place to help me on my efforts to lose some of this weight? ummm yes...

I also want to clarify, I don't just have 50 pounds to lose. I technically have much more than that to lose, I just meant that I had originally lost 50 pounds and was pleased with the difference it made in my life. But I was still obese within the BMI guidelines at 30.29 even if by just a hair. My previous PCP calculated my "ideal weight" as 112 which would be more an 88 pounds weight loss. While I can't even phantom being that weight I think 135 or so would be a good weight for me which would mean a 65 pound weight loss. It might not be much to some people but it is to me.

Some final points. I have been eating better since my band has been empty. I am working hard to drink water, and yes I am frustreated but don't think that means I am feeling sorry for myself. When I say I miss dancing because I don't feel comfortable with my appearance and because I can't keep up I mean just that. The type of dancing I do requires a lot of stamina which I don't have at the time because of my weight gain. THere are women I dance with that are larger tahn me and are able to keep up but I have been really struggling with it and have to stop in class to catch my breath. I can't perform at this level and I miss it terribly. I know that might not sound important but it is important to me.

Again, thank you for taking the time to answer my post and address your concerns.

 

[southernlady]

I am not Diana but I can answer or respond to three parts of this.
1) BY NIH definition, 35 to 40 BMI qualifies for surgery IF comorbids are on board. (For original surgery). Best (and that is the worst word but the only one that works) are diabetes and sleep apnea. Others have a case but those two just about guarantee an approval.
2) Thyroid is not considered a comorbid. That is something totally unrelated to obesity.
3) My starting BMI was 35.2 I only had 68 EXCESS lbs (to get to a 24.999 BMI). I am 5'4" and weighed 203. Yes, 135 is totally a great weight.

 

[VDLT]

@southernlady Thank you so much for your response. I am thankful I do not have diabetes. My husband says I have been snoring significantly and I am thinking a sleep study might be warranted.
And thank you for your opinion on my goal weight. I saw that weight after a medically supervised liquid diet while in college and loved that weight on me for the whole 5 minutes I was at it. That was many moons and many lost and gained pounds ago so I know my fluff will look different at that weight now, but I would still be thrilled at it

 

[DianaCox]

Good answers to challenging comments. I hope you understand the reasons for my comments, and why your initial post elicited them.

I'm not sure what this means, regarding the psych eval triggering a referral to a nutritionist: "I was just wondering if that would takemy request for approval out of the medical necessity category and place me into the lack of weight loss category of insurance coverage." You either have medical necessity for a REVISION (which is different than having medical necessity for band removal), or you don't.

At this time, you do NOT meet the medical necessity requirements for bariatric surgery - none of your comorbidities appear to meet the requirements of being a serious comorbidity of obesity. The general list of serious comorbidities are the following, which have been shown to be improved or cured by bariatric surgery:

• Type 2 diabetes
• Sleep apnea
• Hypercholesterolemia and/or hypertriglyceridemia NOT adequately controlled by statins
• Hypertension NOT adequately controlled by medication
• SEVERE osteoarthritis in weight-bearing joints

Your current problems of hiatal hernia, gastritis, esophagitis and pain in the left shoulder relate to the band, not to morbid obesity, and removing it may be indicated for those reasons, but NOT revision to another bariatric surgery. Hypercholesterolemia - is it or is it not controlled by medication? If it is, it is not a serious comorbidity. And your "thyroid condition" is unrelated to and will not be improved by bariatric surgery - again, not a comorbidity of morbid obesity.

By the way, I hate to be the bearer of possible bad news, but I've heard that the left shoulder pain often doesn't go away even after the band gets removed.

As for the dancing - it appears to me that your issues are related to the fact that you have allowed yourself to become lethargic, unfit and deconditioned. Bigger girls are able to keep up - you need to get your ass to a cardio class and get in better fitness so you can keep up with them!

I still think your best plan is to get the band out now, then deal with your weight later. No revision surgery is going to be an immediate fix for your problems, some of which are remediable by a change in lifestyle and attitude. You probably WILL need bariatric surgery eventually, because you have further damaged your metabolism by getting the crapband and you will gain more weight - but you should start now to make sure that you have insurance that will cover a revision when you do need it, and don't have a policy with the one-surgery-per-lifetime exclusion.

Having said that, you may as well ASK for the revision now - the worst they can do is say no.

 

[Larra]

@VDLT I'm so glad @DianaCox got the conversation rolling, because I read your post and just didn't know what to say to you. She is a much better bad cop that I will ever be. Sadly, I agree with her assessment of your situation and would agree that a realistic goal for now would be to get the band out, which hopefully will improve your quality of life, continue to work on eating healthy and drinking your water, and see what the future holds as regards to your weight and medical necessity for a revision.

I did want to add about the psych eval that it is a totally routine requirement for all forms of bariatric surgery in this country. However, with self-pay patients, as you were back when, often surgeons will just go ahead and operate because why bother when they are being paid up front. I did a psych eval before my DS and I easily met any insurer's medical necessity requirements. It's just part of the process. Same for a session with a nutritionist or dietician. These are just little hoops we all jumped through, but you didn't because you were self-pay. And believe me, some people have much bigger hoops to jump through, like 6 months or longer pre-op meetings with doctor or nutritionist, specific pre-op weight loss requirements, and more. If all that is being asked of you is one little session for a psych eval and maybe one with a nutritionist, consider yourself fortunate.

 

[Larra]

I also should address the comorbidity issue. A comorbidity is a medical condition caused by the presence of morbid obesity. In other words, morbid obesity itself is not a comorbidity, it's the other medical problems that were caused by your obesity, and that may be resolved or at least ameliorated by having bariatric surgery, that count.
Also, people can, and often do, have other medical problems that are NOT comorbidities. For example, your thyroid condition, which is a common medical problem and which will not be resolved no matter what operation you have or how much weight you lose. MO people can, and do, have all the same medical problems as people who are not MO. These are things we have to deal with but they don't count as comorbidities. Your insurer probably has a list of specific diseases that they consider comorbidities, so you can read your policy, though the usual ones are roughly the same with most insurers.

 

[DianaCox]

PS - I hope you recognize that many of us who write advice on these message boards are writing for TWO audiences - the OP and the general readership who learn from the experience of others, either at the same time, or newbies who will come along later and look for advice that exists in the files.

(And I hope you will appreciate that my advice about getting off your ass and getting moving to improve your conditioning is directed not only at you, but at myownself and anyone else who needs to hear that message as well. )

 

[VDLT]

Good answers to challenging comments. I hope you understand the reasons for my comments, and why your initial post elicited them.


I totally understand. Don't worry, I can handle myself

I'm not sure what this means, regarding the psych eval triggering a referral to a nutritionist: "I was just wondering if that would takemy request for approval out of the medical necessity category and place me into the lack of weight loss category of insurance coverage." You either have medical necessity for a REVISION (which is different than having medical necessity for band removal), or you don't.

At this time, you do NOT meet the medical necessity requirements for bariatric surgery - none of your comorbidities appear to meet the requirements of being a serious comorbidity of obesity. The general list of serious comorbidities are the following, which have been shown to be improved or cured by bariatric surgery:

• Type 2 diabetes
• Sleep apnea
• Hypercholesterolemia and/or hypertriglyceridemia NOT adequately controlled by statins
• Hypertension NOT adequately controlled by medication
• SEVERE osteoarthritis in weight-bearing joints

Your current problems of hiatal hernia, gastritis, esophagitis and pain in the left shoulder relate to the band, not to morbid obesity, and removing it may be indicated for those reasons, but NOT revision to another bariatric surgery. Hypercholesterolemia - is it or is it not controlled by medication? If it is, it is not a serious comorbidity. And your "thyroid condition" is unrelated to and will not be improved by bariatric surgery - again, not a comorbidity of morbid obesity.

Thank you this really helps. Thankfully I do not have these issues. While it stinks that it will not qualify me, I am thankful to be relatively healthy despite my weight.

By the way, I hate to be the bearer of possible bad news, but I've heard that the left shoulder pain often doesn't go away even after the band gets removed.

I know, I have heard of folks not getting relief even with removal I just hope it helps, plus I am really concerned that if it is causing these issues who knows what else is going on in there.

As for the dancing - it appears to me that your issues are related to the fact that you have allowed yourself to become lethargic, unfit and deconditioned. Bigger girls are able to keep up - you need to get your ass to a cardio class and get in better fitness so you can keep up with them!

Yep. I really dropped the ball with exercise when life got busy and got soft. I have never been very strong and always had a hard time but have really gotten deconditioned recently. Swift kick received!

I still think your best plan is to get the band out now, then deal with your weight later. No revision surgery is going to be an immediate fix for your problems, some of which are remediable by a change in lifestyle and attitude. You probably WILL need bariatric surgery eventually, because you have further damaged your metabolism by getting the crapband and you will gain more weight - but you should start now to make sure that you have insurance that will cover a revision when you do need it, and don't have a policy with the one-surgery-per-lifetime exclusion.

Having said that, you may as well ASK for the revision now - the worst they can do is say no.

My thought exactly, they might say no, they might say yes, you just never know and it's worth a shot! Thanks so much

 

[VDLT]

@VDLT I'm so glad @DianaCox got the conversation rolling, because I read your post and just didn't know what to say to you. She is a much better bad cop that I will ever be. Sadly, I agree with her assessment of your situation and would agree that a realistic goal for now would be to get the band out, which hopefully will improve your quality of life, continue to work on eating healthy and drinking your water, and see what the future holds as regards to your weight and medical necessity for a revision.

I did want to add about the psych eval that it is a totally routine requirement for all forms of bariatric surgery in this country. However, with self-pay patients, as you were back when, often surgeons will just go ahead and operate because why bother when they are being paid up front. I did a psych eval before my DS and I easily met any insurer's medical necessity requirements. It's just part of the process. Same for a session with a nutritionist or dietician. These are just little hoops we all jumped through, but you didn't because you were self-pay. And believe me, some people have much bigger hoops to jump through, like 6 months or longer pre-op meetings with doctor or nutritionist, specific pre-op weight loss requirements, and more. If all that is being asked of you is one little session for a psych eval and maybe one with a nutritionist, consider yourself fortunate.

I don't necessarily see the need for waiting. Would you mind sharing why you believe it would be wise to wait between procedures versus converting in one procedure? I would prefer to get it all done at once to avoid being under twice and for convenience with work etc. BUT if there would be an advantage to doing them separately I am open to hearing it.

As for the psych eval, I am not opposed to doing it. I am going to get it done on Wednesday. I would have no objection to meeting with a nutritionist for a consultation. I will be completely honest and admit I am hoping I don't have to do a supervised diet. NOT that I am opposed to dieting, I can handle that, it's just that I have not had good luck with medically supervised diets and nutritionists before. I always get someone who wants to base a diet on the food pyramid. That does not work for me at all...

 

[VDLT]

I also should address the comorbidity issue. A comorbidity is a medical condition caused by the presence of morbid obesity. In other words, morbid obesity itself is not a comorbidity, it's the other medical problems that were caused by your obesity, and that may be resolved or at least ameliorated by having bariatric surgery, that count.
Also, people can, and often do, have other medical problems that are NOT comorbidities. For example, your thyroid condition, which is a common medical problem and which will not be resolved no matter what operation you have or how much weight you lose. MO people can, and do, have all the same medical problems as people who are not MO. These are things we have to deal with but they don't count as comorbidities. Your insurer probably has a list of specific diseases that they consider comorbidities, so you can read your policy, though the usual ones are roughly the same with most insurers.

Thank you for the clarification on this. It really helps

 

[VDLT]

PS - I hope you recognize that many of us who write advice on these message boards are writing for TWO audiences - the OP and the general readership who learn from the experience of others, either at the same time, or newbies who will come along later and look for advice that exists in the files.

(And I hope you will appreciate that my advice about getting off your ass and getting moving to improve your conditioning is directed not only at you, but at myownself and anyone else who needs to hear that message as well. )

No worries. I just found an old friend on here by the name of Spiky, she can attest that I can handle myself. And you were absolutely right about getting off my ass. I assure you, there is no need for it to get any wider.

 

[Larra]

@VDLT I think we have a misunderstanding. I am not suggesting that you should wait and have 2 procedures. Unless there is some complication from your band that prevents it, I think it's in your best interest to get the band removed and your revision done at the same time. That way, you only have one round of general anesthesia and recovery, and you will leave the OR with a surgical treatment for your weight no place. It's a win/win.

I would recommend not getting into a discussion about supervised diets with the psych person. That isn't their prevue. Their job is to make sure you understand what bariatric surgery is, that you do not have a classic eating disorder that could get you into trouble post-op (meaning anorexia or bulimia) and that you are psychologically stable to go through the changes that occur post-op. I have no doubts about your ability to pass the psych eval. But the supervised diet stuff is an insurance company requirement, not a psych issue. Or, did you mean discussing supervised diet with the nutritionist? That might be necessary, or they might just focus on what they think you are supposed to eat post-op. Which means their spiel may be geared towards an operation you aren't having, as they tend to give the same info to everyone. Smile and nod, smile and nod.

 

[southernlady]

Smile and nod, smile and nod

YES, THIS!