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What Should You Do When Your Insurance Company Denies Anti-Reflux Surgery After Sleeve Gastronomy?

This is a story we are seeing all too often in our work overturning bariatric surgery denials. It goes something like this:

You’ve suffered from extreme obesity most of your adult life. You tried both medically supervised and self-directed weight loss plans but never succeeded in achieving permanent weight loss.

Maybe you started suffering from comorbidities like sleep apnea, type 2 diabetes, or hypertension and ultimately it was clear bariatric surgery was medically necessary.

After consulting your bariatric surgeon, you undergo a vertical sleeve gastrectomy (VSG), which is now the most common weight loss surgery performed in the U.S.

At first, you are thrilled with your results. You finally see meaningful weight loss that dieting never delivered. More importantly, your comorbidities are resolved, which means you can discontinue using the CPAP machine and perhaps some medications.

But time passes, maybe even several years, and you start suffering from symptoms of severe gastroesophageal reflux disease (GERD) which is a known complication of the sleeve gastrectomy procedure—it can happen even if you never had it as a comorbidity prior to your VSG.

GERD isn’t just occasional heartburn. It can be life-threatening by substantially increasing the risk of developing severe esophagitis, Barrett’s esophagus, dysplasia and esophageal cancers. It may cause additional symptoms such as asthma, coughing, chronic hoarseness and significantly diminished quality of life.

We have overturned denials of anti-reflux surgery after sleeve gastrectomy when payers have tried all sorts of reasons not to pay for the conversion to a gastric bypass, such as:

  • “This procedure is experimental, investigational or unproven…”
  • “Conversion is not medically necessary because the member does not meet our medical policy criteria for a revision…”
  • “Only one bariatric procedure per lifetime is covered…”
  • “Member is no longer morbidly obese, so a gastric bypass is not medically necessary or medically appropriate…”

If your insurance company is forcing you to live with intractable GERD following your sleeve gastrectomy, we can help! Contact us for a free assessment to discuss your options. You don’t have to live with terrible acid reflux just because your insurer says so!

Contact PRIA Appeals to Schedule a Free Assessment

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