Synopsis: A patient needed a revision surgery due to complications from a previous bariatric surgery, but her insurance denied coverage for the procedure, saying that the plan limited members to one bariatric surgery per lifetime. We were able to arrange an independent review (IRO) and obtain revision bariatric surgery insurance coverage for the patient with a successful appeal.
Some insurance payers claim that patients are only covered for one bariatric surgery per lifetime, and deny requests for revisions or conversions of a prior weight loss surgery.
A 51-year-old woman had undergone gastric band surgery in 2005, with an adjustable gastric band. Initially, the surgery was a success. She was “compliant” with her post-operative treatment plan and tried very hard to adjust to the band, but it eventually became clear she was unable to tolerate the band and she suffered from dysphagia (difficulty swallowing) and maladaptive eating patterns.
Because of this, she, like many patients with all types of restrictive procedures (adjustable gastric bands, vertical banded gastroplasties, sleeve gastrectomies, etc.), resorted to a diet of soft, high-calorie foods and liquids. Complicating her situation was the fact she suffered from an acoustic tumor which was going to require inter-cranial surgery—a surgery her doctors would not perform until she lost substantial weight.
To solve the problem, the patient wanted to get a revision from an adjustable gastric band to a RNY gastric bypass. Despite the fact that she weighed 359 lbs. at just 5’5″ and could present several hundred pages of records showing that she was compliant with her treatment plan, her insurer, based in Michigan, denied to cover the procedure for a reason all too many patients confront—plan language limiting the member to one bariatric surgery per lifetime:
“… A member shall only have one bariatric surgical procedure per lifetime unless medically necessary complication to correct or reverse a previous bariatric procedure from complications”
There are many challenges in cases like these. Can it really be established that a “complication” exists, even when there is no erosion, slip, obstruction, stricture or other identifiable “technical defect” in the original gastric banding procedure? And why should the insurer limit the patient to one gastic bypass per lifetime? They certainly don’t limit members to one cancer treatment, one knee replacement surgery, or one diabetes medication per lifetime.
It was nearly too late when she asked us to help her, because she had nearly exhausted her appeals with the payer.
We filed an IRO request as allowed by the plan and Michigan law. We researched the data, got some important input from her neurosurgeon, put together a package and demanded the IRO be done on an expedited basis because of the emergent condition of her tumor.
Within seven days of our filing the request, an independent reviewing physician specializing in bariatric surgery, including revisional surgery (which is not performed by all bariatric/metabolic surgeons), concluded that:
- The removal of the existing gastric band and conversion to a RNY is consistent with the standards of good medical practice
- The procedure is accepted and appropriate for her dysphagia and refractory morbid obesity
- The procedure is known to be effective for her condition
The physician found this was a complication of the original surgery and required the plan to cover her revision notwithstanding the “one surgery per lifetime” exclusion.
Too many times, we hear stories from patients who are suffering from weight regain with a return of comorbidities but there is no identifiable “complication” that can easily be seen after a UGI (an X-ray of the upper gastrointestinal tract) other diagnostic tests.
Something is wrong, but it’s not a complication that appears on an insurer’s non-exhaustive laundry list, so they use the “one surgery” claim to deny coverage. Fortunately, an appeal was successful, and a suffering patient obtained the additional surgical treatment she needed.
Contact PRIA Appeals to Schedule a Free Assessment
If you have been denied insurance coverage for a necessary medical treatment or procedure, PRIA Appeals can help!