Expert: John Pilcher, MD - 5/22/2010

Question
Hello,
I am a former lap band patient who suffered a slip and a leaky band. My insurance company approved removing it and would probably have approved replacing it but I chose a revision to sleeve. The band was removed but the revision was denied as not medically necessary. Since the band was removed in October I've regained much of my weight and now have a BMI over 35. The insurance company has now decided that they won't approve until my BMI goes over 40.

My surgeon and I both think this is crazy. He wrote a letter stating that the standard of care for revisions doesn't require regain, particularly if the previous surgery failed.

Do you know of any written standards for revision that I can refer to in my discussions with the insurance company? Seems to me that there must be guidelines, studies or articles on this.

Any help appreciated!
Britt

Answer
Britt,
I am completely sympathetic with your situation, and I agree it is completely illogical for the insurance company to insist on waiting until you are more heavy (and probably more ill) before they will fund medically appropriate intervention for your weight.

However, it seems that the decision makers at insurance companies don't see things the same way. I regret to say that I don't have any standard or reference that might be used to change their minds.  It MIGHT help if your primary doctor and other physicians besides your surgeon write letters and call the insurance company to question the counterproductive delaying strategy of the insurance company but I have not seen any better options than that.

Best wishes,
Dr JP