What questions should I ask my insurance?

I called my insurance about a year ago to ask about revision. They were extremely vague and left me with no idea whether or not I would be approved. Does anyone know how to narrow it all down to get the right answers? First of all what do I ask to learn if there is a "one surgery for life" exclusion? Next how do I find out if I can get approved under a BMI of 40 if it is to revise? Also does anyone know what is considered "medically neccesary" for a lapband removal? I have had two different complications, one that self corrected after a complete unfill according to the Dr. (though I doubt it since just 6 months later I was experiencing the same troubles). I am waiting to see if the latest issue of dialated pouch and esophagus is better or not. I suspect if they tell me all is well then it will not be deemed neccesary to remove it but I still want to request a revision if this is just going to continue to be a problem. Any thoughts would be helpful.

Thanks!
Sarah

You might try asking your company's HR person.  They might have the information about your employer's insurance policy.  Sometimes the information can be found on your company's website if they are big enough.

 
Your entire policy should be on line.  Go read for yourself and see what it says.  It will outline whether you have WLS benefits or not and if they cover revisions.  Then it will tell you exactly what you need to know.

I would see it with my own eyes if I were you, if you call your ins co you will get a 1st level person.  If you call them three times and get three different people you will likely get three different answers.  So everything you need is right on your policy for you to see yourself.

Ive tried searching my plan online but it does not have direct links to the policy outlining coverage of weightloss surgery and when I type any key words in such as "bariatric", "revision coverage", etc it completely bypasses specific plan information and gives general information about weightloss surgery procedures. I did manage to get a decent operator on the phone today and if she is correct, I do not have a one surgery per lifetime exclusion. She did read it directly to me but said that she could not mail me a copy as it is only available to physicians. She did however read to me that if the lapband has caused a medically neccesary complication such as a slip, or erosion and needs to be removed that revision is an option. She said it depends on the written recomendations of the physician. I guess that means I need the doctor to state that it is medically necessary to remove it and that he recommends a revision. I will know in about two weeks if my esophagus has healed the damage it sustained or not. I imagine if it hasnt then the Dr. will hopefully recommend removal, however if everything looks ok I think it is going to be a major battle to get the band taken out.

This is the criteria from BC/BS NM. I think I have seen mentioned that a few other insurance companies may use the same criteria when it comes to subsequent surgeries that don't qualify under the standard criteria. I hope it helps. 

Gilly

 

MISCELLANEOUS PROCEDURE COVERAGE STATEMENTS

• Bariatric surgery in treatment of Type-2 diabetes mellitus: Bariatric surgery is considered experimental, investigational and unproven as a cure for type-2 diabetes mellitus.
• Repeat/Revision of bariatric surgery: may be considered medically necessary (when specifically included as a benefit or covered service in the member’s benefit plan, summary plan description or contract) only when ALL of the following criteria are met:
  • Original surgery was considered a covered benefit of the member’s current plan, AND the repeat/revision of bariatric surgery is a covered benefit of the member’s current plan; AND
  • For the original procedure, patient met all the screening criteria, including BMI requirements, AND
  • The patient has been compliant with a prescribed nutrition and exercise program following the original surgery, AND
  • Significant complications or technical failure (e.g., break down of gastric pouch, slippage, breakage or erosion of gastric band, bowel obstruction, staple line failure, etc.) of the bariatric surgery has occurred that requires take down or revision of the original procedure that could only be addressed surgically, AND
  • Patient is requesting reinstitution of an acceptable bariatric surgical modality.

Thank you so much!! This looks nearly identical to what she read to me but now I have it in a way to request to my Dr. that we move forward and hopefully he will submit it. I wonder though what they mean precisely by "break down of the pouch".

Thanks again!

You're welcome! I hope it helps.

make sure you go in with a notebook of all your problems, symptoms,  are you having heartburn, are you getting food stuck. what is going on

Tell him that you are tired of all the problems with the band and you want to look into revision.

It can't hurt.  If he knows where you are with everything then he can tell you what he thinks

Tamara