To get help with Insurance Denials for WLS/Revisions

[southernlady]

Welcome Holli sherman
Just a note: http://bariatricfacts.org/threads/insurance-assistance-ds-only-and-a-primer-for-all.5838/

 

[DianaCox]

There are rare cases when an exclusion can be overcome. I’m pretty sure we can get them to cover the removal of the CrapBand, but revision to another procedure is much more difficult. Not impossible, but difficult and be prepared for being disappointed.

If you want it done in one procedure, I would do two or three parallel tracks:
1) Fight to get your insurance to cover it.
2) Find the money to self-pay for the revision at the same time as the band removal - it will decrease the self-pay cost if your insurance is already paying for some of the preop and postop costs, including hospitalization, as well as the OR time and the surgeon and anesthesiologist’s fees.
3) Find the money and support to get both procedures done in MX.

 

[Larra]

I would be very wary about having a RNY gastric bypass (or any other bariatric surgery) coded as "gastric reconstruction". There is no need for gastric reconstruction after lap band removal unless there is some very serious complication from the lap band that has damaged your stomach, and even then, it wouldn't be a gastric bypass. To me (and I am NOT an attorney and can't give legal advice) it sounds like potential insurance fraud.

As Diana said, there is at least some chance they would cover the lap band removal, especially if you have documentation of a complication from the band, but getting around the "one bariatric surgery per lifetime" is very, very difficult. And, I would recommend to anyone considering bariatric surgery to learn everything you can about all your options, including the DS, and if you have a surgeon who doesn't do the DS, find another surgeon, preferably one who doesn't plan on trying to deceive your insurer (though that may have just been his staff and not the surgeon himself). If you can get the lap band removal covered by insurance, I agree that the best course is to have your next bariatric surgery done at the same setting. If they won't cover even the removal, going to Mexico for both is an option. Hopefully you can find some way to care for your family while you're gone.

2 other little thoughts: 1) there may be a reason why that one surgeon is cheaper than all the others, and it may not be a good reason, and 2) since you seem to be in Texas, I would recommend a consult with Dr. Ayoola in Denton. He does the DS and has an excellent reputation.

 

[Holli sherman]

Thanks ladies. I have researched this to death. DS is way to much for me to wrap my head around. May I ask why you recommend this over rny? I never even heard of it until I was looking into revision.

 

[Larra]

You did what you thought was adequate research, but if you had never even heard of the DS, you had not researched all the standard of care bariatric surgeries. I get what you mean about wrapping your head around the DS. It is a complex surgery. As someone who likes to keep things simple, my initial reaction to the DS was somewhat negative as well. But, the more I learned about it, and the more I learned about gastric bypass, the more I realized that gastric bypass was not going to work for me long term and the DS would. Once I made my decision, a sense of peace came to me and I never looked back. Another sad fact here is that your original surgeon clearly failed in his obligation to provide informed consent to you, as that includes informing patients of all their standard of care options, even if he personally doesn't do all of them. We see this all the time.
The DS has the best statistics of any bariatric surgery not just for percentage excess weight loss, but also for maintaining that weight loss, which is a big issue with other operations. Many people lose nicely at first with gastric bypass or sleeve, only to find themselves struggling a few years out. MO is a chronic disease; we need a treatment that works long term. The DS also has the best statistics for permanent resolution of all comorbidities - type 2 diabetes, sleep apnea, etc - except for GERD.
The DS also avoids some of the facets of gastric bypass that makes it hard to live with. With gastric bypass, NSAIDs are contraindicated for the rest of your life. NSAIDs are one of the two most commonly prescribed drug categories, and even if you don't need them now, you may in the future. Dumping is also rare with the DS because the normal function of the pyloric valve is preserved, and dumping is NOT a weight loss mechanism, it is a very unpleasant side effect that some (not all) people with gastric bypass have. We don't have a laundry list of foods that are forbidden forever. Yes, we do need more vitamins and minerals, but some are needed with gastric bypass as well, just less. It is really a much easier operation to live with as well as being more effective.

I would respectfully suggest that you continue your research until you are fully informed about all your options for revision. Once you make your decision, you should feel totally confident that it's the best choice for you.

 

[DianaCox]

"It is really a much easier operation to live with as well as being more effective." This sums it up simply.

The scientific bases of these comparative facts are more complicated, but the bottom line is that the majority of RNYers who are 10 years out have regained much if not most of their weight loss, have regained their comorbidities, and suffer from malnutrition because they have complex micronutrient deficiencies that they have not managed. If you don't comply with your protein, vitamin and mineral requirements with the DS, you'll get sicker faster, but that pressure can help you stick with the relatively simple requirements, and result in a far better outcome and lifestyle.

DSers can eat bacon, mayonnaise, butter, etc., and steak, lobster, eggs, cheese, with relative impunity (within reason). An occasional carb splurge is likely to merely result in a longer bathroom visit the next morning, and not immediate rolling on the floor in pain/nausea from dumping. I'm 15 years out and easily maintaining my weight loss, almost at my lowest weight, without being on a restrictive diet,. and my labs are excellent. Not many RNYers can say that.

 

[Angelina Frazier]

I am a rnyer, am over 14 years out and have gained just about all of my weight back. If I had know about DS back then I would have gotten it.

 

[GrammyLuLu]

I was in the same boat as Angelina and just had a revision from Rny to DS and let me say if I had been able to have the DS to begin with it would have been my first choice hands down. The dumping was horrible the only consolation was that I knew it would go away. Reactive hypoglycemia was another thing I struggled with and that would happen without any warning. Continue to do your research and make the right decision for you. You dont want to have to have yet another surgery.

 

[Whit]

I also revised from RNY to DS. It has been 5.5 years. I would in no way recommend RNY to anyone. While it does work long term for a few it doesn't for most. I had dumping, marginal ulcers, and gained back almost off of the weight I lost in about 5 years.

 

[Angelina Frazier]

I was in the same boat as Angelina and just had a revision from Rny to DS and let me say if I had been able to have the DS to begin with it would have been my first choice hands down. The dumping was horrible the only consolation was that I knew it would go away. Reactive hypoglycemia was another thing I struggled with and that would happen without any warning. Continue to do your research and make the right decision for you. You dont want to have to have yet another surgery.

I also revised from RNY to DS. It has been 5.5 years. I would in no way recommend RNY to anyone. While it does work long term for a few it doesn't for most. I had dumping, marginal ulcers, and gained back almost off of the weight I lost in about 5 years.

Please can u tell me do u live near TX, who did your surgery, how much. Do u know any company's I can apply for a 2nd job with because my current job insurance does not cover wls or programs.

 

[DianaCox]

In TX, the only option is Dr. Ayoola in Denton.

With all due respect, you're going to need to be more focused and considerate of other people's time in asking your questions on a website such as this. How can we possibly know of companies you can apply to for a second job when we have no idea what your education, skills or experience are, what companies are hiring, or what their benefits are? We don't even know where in TX you live. Nor, for that matter, whether you are capable of doing a second (full time?) job - why not just find a BETTER first job that has good insurance?

 

[GrammyLuLu]

Please can u tell me do u live near TX, who did your surgery, how much. Do u know any company's I can apply for a 2nd job with because my current job insurance does not cover wls or programs.

I live in Arizona and had Dr. Steven Simper perform my revision who is in SLC. Unfortunately I do not have any employment advise for you. I did self pay for my revision.

 

[Angelina Frazier]

In TX, the only option is Dr. Ayoola in Denton.

With all due respect, you're going to need to be more focused and considerate of other people's time in asking your questions on a website such as this. How can we possibly know of companies you can apply to for a second job when we have no idea what your education, skills or experience are, what companies are hiring, or what their benefits are? We don't even know where in TX you live. Nor, for that matter, whether you are capable of doing a second (full time?) job - why not just find a BETTER first job that has good insurance?

Thanks for responding. However, when I posted the question I was thinking about companies in general that have multiple positions for various education levels, such as hospitals, amazon and the like. Since I am willing to clean toilets, type contracts, bath and provide services for Intellectually disabled/handicapped/ mentally I'll. However I understand what u mean about being specific about my expertise, so I will, but keep in mind no job is too big or small (with in reason). I have a MS in Psyc, BS in Psyc/HRM. I have run entire mental health and IDD programs and divisions, which is what I am currently doing, I've also served as administrative secretary and assistant, and would like to work a second FT position, unless the money and company is awesome. Note:Being in Social Services for so long U become accustomed to not getting paid your worth. I can message more of a resume individually, I dont think everyone wants to read all this. Thanks and I welcome information.

 

[Holli sherman]

I would be very wary about having a RNY gastric bypass (or any other bariatric surgery) coded as "gastric reconstruction". There is no need for gastric reconstruction after lap band removal unless there is some very serious complication from the lap band that has damaged your stomach, and even then, it wouldn't be a gastric bypass. To me (and I am NOT an attorney and can't give legal advice) it sounds like potential insurance fraud.

As Diana said, there is at least some chance they would cover the lap band removal, especially if you have documentation of a complication from the band, but getting around the "one bariatric surgery per lifetime" is very, very difficult. And, I would recommend to anyone considering bariatric surgery to learn everything you can about all your options, including the DS, and if you have a surgeon who doesn't do the DS, find another surgeon, preferably one who doesn't plan on trying to deceive your insurer (though that may have just been his staff and not the surgeon himself). If you can get the lap band removal covered by insurance, I agree that the best course is to have your next bariatric surgery done at the same setting. If they won't cover even the removal, going to Mexico for both is an option. Hopefully you can find some way to care for your family while you're gone.

2 other little thoughts: 1) there may be a reason why that one surgeon is cheaper than all the others, and it may not be a good reason, and 2) since you seem to be in Texas, I would recommend a consult with Dr. Ayoola in Denton. He does the DS and has an excellent reputation.

Thank you for your recommendation. I do have serious complications from the band and it has damaged my stomach as it is twisted and the band sits up way to high which is why it has never worked. He said there is not a point to it because it did not do anything but just sit there. I have just had a Scope last Tuesday and they are submitting for the removal of just the band. Also this Doctor has well over 20 plus years at this location. They are very well known. Gastric Reconstruction is just another code that is used does not mean they are doing any insurance fraud. Just means it will not be coded as bariatric as the removal part will not be bariatric as it is a complication and no other bariatric will be preformed. I have to do two stages in order for that to be covered.. I have also contact Dr. Ayoola in Denton and his cash price cost is 30k with removal and the hospital in Flower mound for DS. If Insurance does not approve the code for Gastric Reconstruction then I am all cash pay and finding a doctor that I can afford is my choice. If I am spending my own money, not financing it, charging it, JUST my savings I am smart enough to find one that has a reputation and experience. I appreciate your concern.

 

[Holli sherman]

Thanks for responding. However, when I posted the question I was thinking about companies in general that have multiple positions for various education levels, such as hospitals, amazon and the like. Since I am willing to clean toilets, type contracts, bath and provide services for Intellectually disabled/handicapped/ mentally I'll. However I understand what u mean about being specific about my expertise, so I will, but keep in mind no job is too big or small (with in reason). I have a MS in Psyc, BS in Psyc/HRM. I have run entire mental health and IDD programs and divisions, which is what I am currently doing, I've also served as administrative secretary and assistant, and would like to work a second FT position, unless the money and company is awesome. Note:Being in Social Services for so long U become accustomed to not getting paid your worth. I can message more of a resume individually, I dont think everyone wants to read all this. Thanks and I welcome information.

Lane Bryant used to cover weight loss surgery when I worked for them full time.