Any Revisioners successful appealing the insurance denial based on not having six months...

I had Lapband surgery in 2006.... was not successful (and I don't blame the band for that but rather me and the band).  I started researching a revision to the sleeve.  I confirmed that my insurance - United Healthcare - does cover it.  I moved to another state; found a new surgeon and started on the approval path.  My new surgeon had an Upper GI done and found that my band had slipped up onto my esophagus - is not even on my stomach.  He completely unfilled it which helped my reflux, sliming and food getting stuck symptoms. 

Paperwork was submitted to UHC (they were not my insurance carrier for the Lapband surgery btw).  They immediately approved my Lapband removal but not the Sleeve revision because I had not done a six months pre-op diet.  To me this is so completely ridiculous of a requirement for a WLS revision - I mean effectively wasn't having a Lapband for the last 5+ years being on a diet?  Here is the wording of the letter they sent:

"Diagnosis: esophageal reflux,vomiting, abnormal weight gain

Type of treatment: longitudinalgastrectomy


The service is not recommended asmedically appropriate for the following reasons(s):

Authorization for Sleeve Gastrectomy isnot recommended, as clinical criteria for this procedure are not met.For example, per SPD: Recent history and documentation in MD notesthat the pt has participated in and reasonably complied with at least1 physician-supported weight loss program (including nutritionalanalysis, education and regular clinical encounters with a healthprofessional), documented by a physician who does not perform weightloss surgery, lasting for a minimum of six (6) cumulative months andoccurring within two years prior to surgery. Also dietary therapy,i.e., restricted calorie diet, increased physical activity i.e.,exercise program, behavioral therapy to reinforce dietary therapy andincreased physical activity."

I have started a pre-op diet with my Primary Care Doctor and am already a month into it - lost 4 lbs this month.  However, I just don't see any real reason I should have to prove once again that long term I don't have success with dieting and I need a permanent solution.  Heck, 10 years ago I lost over 100 pounds on Weigh****chers and I gained 80 of that back before having Lapband. 

I realize some may think I should post this in the Insurance section - and I may do that; but I feel it's pretty specific to people who have had Revision Surgery.  I fully understand the six month pre-op for those seeking WLS approval for the first time - I had to do it back in 2005-2006 to get approved for the Band. 

Would love to hear from anyone who has successfully appealed the same criteria - if anyone is out there who has.  I'm pretty much resigned to go through the full six months and have surgery early next year - just feel like it's more months that I will remain morbidly obese and at risk of all of the complications that come with that.

I appreciate any and all responses.

Thanks.

Susie

I revised from RNY to DS due to esophageal erosion (my rny had an extra ring around the stoma, creating a combo rny/vbg). I started the 6 month diet while waiting for test results but Blue Cross approved me right before the 5 month mark. I had the bulk of my tests in Sept. 09, had surgery in Dec.

You can appeal, but by the time you do, you'll have the 6 mos of diet.

I agree it is absolutely stupid but remember who you are dealing with.Like the OP said by the time you appeal it you'll probably be done with the 6 mos. It couldn't hurt tho to go ahead and appeal you might get lucky if both you and your surgeon point out that you've already done this and that this is a revision not a "virgin" WLS. Good luck!

I'm at the end of my six month program with Kaiser - it actually took me longer due to an employer who didn't like the idea of my taking time off for the monthly appointments with the nutritionist , so I've actually been going through the program since 12/2010.  At first, I was frustrated over the requirement of the six month program.  I'm seeking a revision (Fobi procedure) and of course diets weren't successful - if they were, I wouldn't be in this position.  On the other hand, now that I've gone through the program, I realize that it has given me the understanding of why I regained the weight I lost.  I know why I ate the wrong things when I did.  I know when I come home tired from work and pick up the phone to order a pizza that I'm only doing it because I'm exhausted.  I think, "Why am I doing this when I'm going to have to wait 45 minutes for a delivery, pay $15-$20, and only eat two slices max?  There's a lean cuisine in the freezer and it can be ready in five minutes."  That's when I hang up the phone.  I also know that I tend to eat the wrong things in social situations.  That's also under control now and I order healthier items from the menu, choose restaurants carefully, etc.  Admittedly, if I go to NYC for the weekend, I am going to have treats but that's not every other day after work like it used to be.  Accept the fact that there are times when the insurance company (AND YOUR NUTRITIONIST) know more than you do and use the program so you have the tools you need to be successful this time around.

Many thanks for your responses.  I still intend to appeal - even if it ends up taking close to the six months that I have to be on the pre-op diet.  I am just waiting or some medical records from the Dr.'s in my previous state since I just moved to FL five months ago.  I figure worst case I finish the six months in February and they stated no other reasons for the denial.  I'll get the psych and nutrition consult before then also.

Thanks again.

Susie