Over the last four years, the field of weight-loss surgery has grown at an exponential rate. As a result, I’m receiving an increasing number of questions about post-operative surgery. The sheer quantity of post-op patients is boosting the demand for these two sorts of post-op operations, whether it’s plastic surgery or a revision.
The word “revision” means “to change or amend” (for our purposes, it is to change or modify a prior bariatric surgery). Revisions are possible in a number of areas. A patient will either be undergoing a revision of a failed bariatric procedure or undergoing a revision to a new type of technique that was not approved or even available at the time of the original surgery.
This is a basic question with a more complicated answer. Insurance firms, as we all know, appear to make choices by tossing darts at a dartboard. As a result, it’s only normal to suppose that a supplier will respond differently to various people from different states.
To begin, a request for a revision based on a failed prior bariatric surgery would elicit a response from most insurance providers, who will query whether the earlier surgery genuinely failed or whether the patient was just not adhering to the initial operation’s guidelines. To put it another way, you’re eating past the pouch or band.
Similar questions will be asked about a revision from a previous treatment to a new type of procedure, as well as why the patient wants to transition from a Roux-en-Y to gastric banding or duodenal switch.
It’s critical that you and your surgeon are on the same page before making such a request. He or she should be aware of the specific reason for the operation, as well as any challenges you had with compliance during the initial process. Never wait for the insurance company to inquire about the matter. When your surgeon sends a request for authorization, respond to it.
If the pouch stretched, the staple line failed, the band slipped, or the bypass just didn’t work, you’ll need pre-op testing to back up your claims. You should obtain the results of an MRI, CT scan, or endoscopy before applying for certification. Similarly, you should give the surgeon a basic summary of your compliance throughout time, including a diet and exercise history.
It’s likely that your BMI has been low in the past and that you no longer have any substantial co-morbidities. In this situation, you’ll make sure the carrier understands that if the modification is denied, it’ll only be a matter of time before your BMI becomes even higher and your co-morbidities resurface. If you’re requesting a new type of surgery, one that didn’t exist when you last had one, make sure to highlight the reasons why this operation is suited for you in your surgery request. By answering the insurance company’s questions before they’re asked, these preemptive strikes may just gain you the clearance you need.
I’m sure you’re thinking something along those lines. Assume that my insurance company does not cover bariatric or weight-loss surgery, or that it does not cover it any longer. In such case, you’re going to dispute over two things. First, weight-loss surgery should be covered because it is used to treat co-morbidities such as diabetes and hypertension in addition to obesity. Second, this is a request to fix a failed procedure that may result in serious complications in the near future, not for obesity or weight loss. The latter is a more difficult argument to make, but one that has been effectively stated. Remember, just like with your original surgical request, you must document your claims. And, of course, never, ever, ever, ever, ever, ever, ever, ever, ever,
How do you qualify for gastric bypass revision?
Your body mass index, a numerical number of your weight in relation to your height, plays a role in determining your eligibility for bariatric surgery. The BMI range of 18-24.9 is seen as ideal. A BMI of 40 or higher is considered morbid obesity.
If you have a BMI of 35-39 with particular serious health concerns like Type 2 diabetes, sleep apnea, or high blood pressure, you may be a candidate for bariatric surgery. A BMI of 40 or more is also a requirement.
Can a revision be done on a gastric bypass?
Bariatric revision is an endoscopic treatment used to help individuals who have had a gastric bypass but have gained weight since the procedure. A transoral gastric outlet reduction is another name for this operation.
Will insurance cover a second weight loss surgery?
- Conversion Surgery is a technique that allows you to go from one type of bariatric procedure to another. Lap band to gastric sleeve or gastric sleeve to gastric bypass are the only two treatments that can be converted. Both become permanent after that.
- Surgery to restore the effectiveness of the original bariatric treatment is known as revisional surgery. Revisional surgery is any operation used to treat failing weight reduction after a gastric bypass or gastric sleeve.
Insurance companies currently consider revisional surgery options to be experimental or investigational. The following are examples of revisional procedures:
Your insurance plan may not cover a second procedure. You’ll need to go over your plan to see what your coverage options are and what standards you’ll need to meet in order to be considered for another weight reduction procedure.
Laparoscopic Revision of Band to Laparoscopic Sleeve Gastrectomy
In a revision band to sleeve gastrectomy, the band and all surrounding scar tissue are removed first. The sleeve gastrectomy is performed after the band, port, and scar tissue have been removed. If a patient has a hiatal hernia, it will be repaired at the same time as the procedure. In most cases, patients can lose 65 percent of their excess body weight, or 65 pounds for every 100 pounds they are overweight. Patients might expect to be out of commission for 1 to 3 weeks. When compared to a simple sleeve gastrectomy, the complication rates are minimal and comparable.
Laparoscopic Revision of Band to Laparoscopic Roux-en-Y Gastric Bypass
According to studies, converting a band to a laparoscopic gastric bypass is the gold standard for a revision band operation. A band to gastric bypass, like other band revisions, is done in a single stage with only one operation. We remove the band, port, and scar tissue first, then proceed with our gastric bypass, similar to a band to sleeve revision. The risks of complications are the same as for a gastric bypass performed on someone who has never had surgery before, as is the recuperation time, which is 1 to 3 weeks. A normal patient can lose 75 percent of their excess body weight, or 75 pounds for every 100 pounds of excess body weight.
Is StomaphyX covered by insurance?
Depending on your surgeon and where you live in the country, the procedure might cost anywhere from $8,000 to $13,000.
Due to the scarcity of research documenting the procedure’s outcomes, insurance companies rarely pay it. There are, however, a number of viable bariatric surgery financing solutions available to help pay for some or all of the procedure.
As previously said, we highly advise against doing this operation until more data confirming its efficacy and safety is available.
Can u have a second gastric bypass surgery?
A second surgery to correct or redo a gastric bypass may be necessary in some situations. This is especially true if your stomach and small intestine anatomy has changed, as in the case of a fistula (additional connection between the stomach and intestine).
How long does a gastric bypass revision take?
How long does bariatric surgery take? True You’s endoscopic gastric revision surgery is done as an outpatient procedure that takes around 30 minutes to complete under minimal anesthesia.
Can you have a Rny revision?
The StomaphyX treatment is an unique and revolutionary revision therapy for people who have regained weight after Roux-en-Y gastric bypass surgery due to a stretched stomach pouch or expanded stomach outlet. StomaphyX is a treatment that shrinks the stomach pouch and stomach outlet (stoma) to the original gastric bypass size without typical surgery or incisions and with short recovery time. It was approved by the US FDA in 2007. It is used as a type of revisional bariatric surgery for gastric bypass patients, rather than as a primary technique of weight loss surgery.
What is Candy Cane syndrome?
Candy cane syndrome is a rare complication that has been documented in bariatric patients who have undergone Roux-en-Y gastric bypass surgery. It happens when the roux limb is excessively long proximal to the gastrojejunostomy, allowing food particles to lodge and persist in the blind redundant limb. Patients complain of non-specific symptoms such as stomach pain, nausea, and vomiting. Because the disease process is inadequately documented, the majority of people go undetected. Three cases of candy cane syndrome were successfully treated at our facility.
What if insurance doesn’t cover weight loss surgery?
After you’ve weighed your alternatives and decided that bariatric surgery is the best option for you, you’ll want to know how you’ll pay for it. Many insurance companies acknowledge the importance of obesity and its health repercussions, and will pay for weight loss procedures if you meet plan-specific eligibility requirements.
How to verify your own benefits
Although the staff at your surgeon’s office will verify your benefits as a courtesy, it’s a good idea to call your insurance carrier to confirm coverage and restrictions. You can also read the coverage documentation that your employer and/or insurance company have issued to you.
You’ll want to know if bariatric surgery is covered; if it isn’t, it’ll most likely be included under “obesity” or “weight reduction surgery” in the plan’s exclusions. Bariatric surgery is commonly described as being covered if it is medically required, but this is only partially accurate because it must also be a covered benefit.
You’ll want to know what’s required once you’ve confirmed that your plan covers bariatric surgery. Each plan has its own set of criteria and regulations for determining medical necessity to your insurance carrier’s satisfaction. Although your carrier’s medical policy is the most typical place to obtain benefit criteria, your employer may have an addendum document (“summary plan document/description”) that explains extra or other requirements for particular treatments. Because the requirements of the medical policy are often superseded by a summary plan document, it’s crucial to know if an addition like this applies.
Medical necessity vs. coverage exclusions
Despite the fact that you may meet basic and widely accepted medical necessity requirements, your insurance company is not compelled to cover bariatric surgery. Your insurance will not consider you for coverage if weight loss surgical services are designated as an exclusion, regardless of your BMI or concomitant conditions. The denial rationale does not imply that surgery is not medically required, but rather that they do not give this form of coverage, for which there is no appeals process.
Cash paying for surgery
There are alternative solutions open to you if your insurance does not cover bariatric surgery. Consultations, nutritional counseling, pre- and post-operative tests, labs, and follow-up visits may be covered depending on the plan language, but surgery is not. Verifying your benefits will assist us in estimating potential costs for you during your appointment.
How to meet insurance criteria
You’ll meet with a surgeon for a consultation once your benefits have been validated. Your height, weight, and BMI will be recorded, as well as any concomitant conditions and previous unsuccessful attempts at non-surgical weight loss. If your plan calls for a medically supervised weight loss program, you’ll meet with a nutritionist on a monthly basis for the duration of your treatment.
Because a psychological clearance is the most prevalent insurance criterion, you should make an appointment with a mental health specialist who will assess your candidacy for bariatric surgery. It’s crucial to rule out psychological issues, any type of disordered eating, a lack of competence to provide informed consent, and a failure to follow pre- and post-surgical instructions.
Insurance authorization process
The authorisation process can commence if all pre-surgical and insurance requirements have been satisfied. Your pertinent medical records will be compiled and sent to the clinical review department of your insurance company. A determination can take up to four weeks, but it is more common to receive one in two weeks. You’ll be advised of the approval or denial once we hear from your insurer. Surgery can be planned or confirmed once you’ve gotten approval.
If your operation is denied, we will examine the decision and follow the measures provided by your insurance company. Denials can occur for a variety of reasons, including a lack of paperwork or a lack of agreement on criteria that are ambiguous or open to interpretation.
Appeals
Because appeals deadlines may be approaching quickly, it’s critical to properly evaluate denials.
As a first step in this procedure, a peer-to-peer option is usually provided. A peer-to-peer meeting is a prearranged meeting between your surgeon and the medical director of the insurance company to address the denial. When this conference is feasible, it’s quite beneficial since we can get precise input from a reviewing authority about what additional the insurance company expects us to provide or what they want you to accomplish in order to qualify. At the time of this debate, the rejection may be affirmed or reversed, but it’s usually just a tool for moving forward with the appeal.
If an appeal is necessary, we will obtain any additional documentation that was previously overlooked. If more tests or office visits are needed, they should be planned as quickly as possible to ensure that they are completed before the appeal time expires.
There could be several stages to the appeals process. A second- or third-level appeal can be requested if necessary, with the final step typically including submission to an outside party for review. Because external review organizations are not linked with our office or your insurance provider, they can conduct an unbiased assessment of your clinical documentation.
What can I do to ensure approval?
A patient health history questionnaire will be given to you prior to your session. Because it will be translated into your medical record, which will be evaluated by the insurance provider, it is critical that you fill this out entirely and truthfully.
Bring a copy of any paperwork (medical chart notes, personal records, logs, or receipts) from past weight loss attempts, whether by diet, exercise, or medical supervision, to be reviewed and scanned into your chart.
If you’ve had a previous weight reduction treatment, you should get copies of your operative report, as well as pre- and post-surgical visits, to demonstrate your commitment to follow-up and adherence to any suggestions provided by your previous practitioner.
The single most important thing a patient can do to increase the chances of their insurance company approving their claim is to follow the medical policy’s rules to the letter (or Summary Plan Document, if applicable). Medically supervised diets are generally need to be followed for several months and should be spread out by about 30 days. Failure to keep scheduled appointments for several months in a row will almost always result in denial, delaying surgery or forcing you to restart the prescribed regimen from the beginning.