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matdeb85
Member Since: 01/14/12
[Latest Posts]
Post Date: 1/16/12 6:18 am
I am a little over three years post lap band. After two years my band slipped, Anthem paid for this fix without and issue. Sevens months later a severe infection was found treated but returned. This happened four times before the figured out my band was infected, my doctor said I easily could have died. So in April of 2011 I had to have the band removed and I can not even begin to explain what this did to me, I cried for days. I had just spent over two years getting to the point with my weight that I was thrilled. My surgeon told me after six months we could do a sleeve. She thought that since it was a revision and I had been so sick that the approval should have been easy......well as I am sure you can guess it is not. First off, for some reason the reviewing doctor apparently did not read my record as his decision was bases on the fact that my BMI was to small to be even considered for weight loss surgery. He somehow completely missed that original surgery and that this pre-authorization was for a revision. I am hoping my surgeon can get this straightened out but if not has anyone any advice for dealing with Anthem? Has anyone been successful in an appeal with them?
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Vicki Browning
IN
Lap Band (08/31/07)
Member Since: 10/12/07
[Latest Posts]
Post Date: 1/19/12 9:07 pm
Here is the Anthem Medical Policy regarding revisions or change to different procedure after complications, hope this helps and hope that you will be approved.  It will be a fight I am sure but don't give up.

Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, (i.e., unrelated to a surgical complication of a prior procedure) are considered medically necessary when all the following criteria are met:

  • The individual continues to meet all the medical necessity criteria for bariatric surgery (see page 1); and
  • There is documentation of compliance with the previously prescribed postoperative dietary and exercise program; and
  • 2 years following the original surgery, weight loss is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight (taken from standard tables for adult weight ranges based on height, body frame, gender and age, an example is available from the National Heart Lung and Blood Institute [NHLBI] at: http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm.


 

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matdeb85
Member Since: 01/14/12
[Latest Posts]
Post Date: 1/20/12 5:42 am
Thank you for the reply and I do know these requirements but my revision does not fall into this categor, mine is in the medical necessaty because of the fact the infection in my band almost killed me.I have been talking with BC/BS all week and since my revision is caused by this infection to the device implanted there are no requirements to meet as I had no chioce in having it removed, an I had lost all the weight I needed too. This automatically qualifies me for the revision. What I have found out from Anthem themselves is that their doctor for reason's they do not understand never read my file and denied my revision on the grounds that he thought it was my first surgery. I was really surprised when BC/BS admitted this to me and I think they have been angrier than I was. As we speak my surgeon is having a peer to peer review to makes sure this time it is clear why this revision is necessary. I am more than a little concerned however because if he did not read my information where very clearly in the second paragraph states that the revision is for a failed Lap Band, one has to wonder what else this doctor may have missed for other people.
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