This is what my plan says :
Surgical Revision
Members are eligible for coverage of a surgical revision of a previous gastric restrictive surgery if it is medically necessary as a result of a complication of the original procedure; i.e.:
1. Staple disruption.
2. Obstruction or chronic stricture.
3. Severe esophagitis.
4. Dilatation of the gastric pouch in a member who experienced appropriate weight loss prior to the dilatation.
Note: Laparoscopic adjustable banding revisional surgery will be covered for band slippage or erosion, both of which are deemed urgent medical conditions.
Surgical Repetition
Members are eligible for coverage of repeat bariatric surgery if both of the following criteria are met:
1. Insufficient weight loss (success defined as a weight loss of > 50% of excess body weight) within 2 years post primary procedure.
2. The medically necessary criteria (as outlined above) are met.
Note: Member compliance with prescribed postprocedure nutrition and exercise program is prerequisite to consideration.
This is a re post of an old reply of mine, I hope someone will find it useful.
Your insurance company may be stringing you along regarding the having to be obese rule for two years. What's to stop them from saying that you do not qualify because of you not being a " good " candidate for WLS because of your regain.
They are sneaky, underhanded, unethical, bastards who will use your regain against you. They don't care that you were unable to follow the Lap Band rules, because following them as you did caused you to suffer tremendous pain.
I urge you to try the following while you are working your insurance company for your revision:
1. You must "on paper" go back to being the model patient, but be sure to report how that isn't working and how much it hurts.
2. You must faithfully log your surgeons lap band eating program everyday down on paper.
3. On that paper you will record what you ate, log in the correct amount of protein according to your surgeons eating program.
4. Log in your water.
5. Most importantly...you will need to log in every bit of pain and it's location, and whether that pain was dull, sharp, stinging, numbing, burning.and it's duration. You need to long in how long that food remained stuck in your esophagus and when and if you had to bend over the toilet to release it. Record every instance of acid reflux,rate the pain and degree of burn and if you ever start to spit or throw up bloody mucosa...you better record that too, and then cry like a baby and call your surgeon.
If you experience port swelling,tenderness,burning and bee like stinging sensations record it. This may be a sign of infection which may be a sign of erosion.
6.You must walk these recorded Adverse Events into your band surgeons office every month. You don't need an appointment to do this. You just walk up to the receptionist, hand her the original ( you keep a copy at home ) Then you kindly tell her that you want these lap band problems that you are currently experiencing to become part of your permanent medical record.
You kindly instruct her to time and date stamp it and have her sign it as well. If she tells you they don't have a stamp, then kindly instruct her to do it in writing.
Here is the most important part...After she times,dates, and signs it, you make sure she gives you a copy of it. This way they can't toss it and you have documented proof of all your current Adverse Events.
After she hands you back your signed copy. Look to see if her signature is legible. I suspect she will only initial it and her initials will be really strange looking. Make sure you get her name and print it on that letter. If she has a name plate in sight...you can get her last name too.
7. The next time you see your surgeon YOU write down all your Adverse Events and bring along a written copy of that months journal. You give it to the person who is charting your vitals and tell them you want it added to your permanent medical history ( make sure it's dated ) Now you will repeat the process regarding acquiring a signed and dated copy for your medical records.
Every time you go to a doctor/surgeon appointment. The office staff is trained to only write down your primary complaint. They look like they are writing everything down , but they aren't. They may write down a second complaint, but it's doubtful.
Try it, go on in with a list of memorized complaints and then when they are all done charting your vitals, and right before they leave the room. ASK them to repeat it all back to you. It is very rare for them to record every single event that you told them about. You don't know which event you reported will become important to your case in the future. Don't assume it was recorded...Make sure it was recorded.
8. When the time comes for another ER visit. You arrive with a list of your symptoms and have them record them, tell them your weight too.
9. you must learn to document everything.
10. If you have ever taken any NSAIDS....you didn't.
11. Record all Lap Band approved medications per your surgeons pre- op booklet and when and why you took them.
There's more, but I need to tell you something else.
That food that gets stuck in your esophagus...
I suffered on and off for years with food that was stuck and wouldn't go down, chest pain, ear aches, and neck pain that was wrongly diagnosed as anxiety attacks/panic attacks. Sometimes I would grab my inhaler because I thought it might be the start of an asthma attack.
What is esophageal spasm?
Esophageal spasms are irregular, uncoordinated, and sometimes powerful contractions of the esophagus, the tube that carries food from the mouth to the stomach. Normally, contractions of the esophagus are coordinated, moving the food through the esophagus camera and into the stomach.
There are two main types of esophageal spasm:
* Diffuse esophageal spasm. This type of spasm is an irregular, uncoordinated squeezing of the muscles of the esophagus. This can prevent food from reaching the stomach, leaving it stuck in the esophagus.
* THIS IS IMPORTANT TO UNDERSTAND because many banded people think that their food is stuck due to not chewing well or they think they ate too fast.
*
* Nutcracker esophagus. This type of spasm squeezes the esophagus in a coordinated way, the same way food is moved down the esophagus normally. But the squeezing is very strong. These contractions move food through the esophagus but can cause severe pain.
* Again, this is often explained away by band surgeons and banded patients as eating to fast and/or not chewing well enough.
You can have both types of esophageal spasm.
After many ER visits, doctor visits, specialists, procedures and hospital admissions still being wrongly diagnosed. I was finally diagnosed with dysphagia ( difficulty in swallowing ), and esophageal motility disorder ( difficulty in swallowing,regurgitation of food and esophageal spasms)
Check out this link and then see if your surgeon or PCP can order you this test.There is a lot of really useful links here.
What is achalasia?
www.medicinenet.com/achalasia/article.htm#tocbEsophageal manometry
Another test, esophageal manometry, can demonstrate specifically the abnormalities of muscle function that are characteristic of achalasia, that is, the failure of the muscle of the esophageal body to contract with swallowing and the failure of the lower esophageal sphincter to relax. For manometry, a thin tube that measures the pressure generated by the contracting esophageal muscle is passed through the nose, down the back of the throat and into the esophagus. In a patient with achalasia, no peristaltic waves are seen in the lower half of the esophagus after swallows, and the pressure within the contracted lower esophageal sphincter does not fall with the swallow. In patients with vigorous achalasia, a strong simultaneous contraction of the muscle may be seen in the lower esophageal body. An advantage of manometry is that it can diagnose achalasia early in its course at a time at which the video-esophagram may be normal.
Christ, I could go on and on, but I'll shut up now...
