I am in need of a revision from my Lap Band to Gastric Bypass surgery due to complications. My Dr. submitted all the information in the pre determination letter and all the codes and the past problems that keep re occuring, and in one denial letter they said I no longer met the criteria, but I am told that I do by the Dr. I am still obese and my BMI is 37.4 and I still have hypertension, and high cholesterol and take medications for this. Now I have again a mega esophagus and a narrow esophagus of 2mm--no food will pass through. My Lap Band was un filled and I have been placed on a special diet hoping that some good will come from all of this.
Hi Roxxie2u - I am sorry to hear that your Lap Band surgery has not delivered the results you hoped to achieve. You may want to read my shareposts on the Pouch Rules for Dummies and Why Weight Loss Occurs from Obesity Surgery. There may be some useful information in thoses posts that will help you lose weight while you sort out your revision approval with your insurance company.
By and large, BCBS does cover gastric bypass surgery. However, the particular coverage depends on the plan that you have, and qualifying for this coverage depends on the plan's acceptance criteria, and how you measure up against that in the eyes of the reviewer making the determination.
Will your surgeon's office appeal the denial letter? Sometimes with insurance companies it takes persistence. It might be helpful if you can find out exactly why the insurance co finds that you no longer meet the criteria. Obviously, your surgeon finds that you do.
Also... in case you want to discuss your revision surgery with other bariatric surgeons:
The American Society for Bariatric Surgery (ASBS) has a searchable database on their web site to help patients find quality doctors and hospitals. These surgeons and hospitals must meet certain criteria and stringent guidelines setup by the ASBS in order to be labelled "a Center of Excellence" and be included on this list.
Phone the practice and explain your denial letter and ask how they'd handle it. Some practices are more assertive in appealing claims than others.