Beat One Surgery Per Lifetime Exclusions!

Exclusion for “One Surgery Per Lifetime”?!? Not So Fast…..

Remember the classic Seinfeld character “The Soup Nazi”?  If you didn’t follow his rules you’d get thrown out of line – – “No Soup For YOU”.  Some payers seem to take the same approach when it comes to requests for revisions or conversions of a prior weight loss surgery.  Instead of yelling “No Soup For You” they tell you something like “ONLY ONE SURGERY PER LIFETIME NOW GO AWAY!”  You shouldn’t go away….here’s a quick case study of a woman who demanded her “soup.”

This 51 year old woman asked us to help her get a revision from an adjustable gastric band to a RNY gastric bypass.  At 5’5″ and 359 lbs. and a BMI of 59.9 it’s hard to believe this insurer, based in Michigan, would deny her this procedure . . . OK – so it’s not so hard to believe – after all this IS an insurance company we’re talking about, right?

While she initially was successful with her band after she got it in 2005, and despite she had presented the insurer with several hundred pages of records showing that she was “compliant” with her post-operative treatment plan and tried very hard to get properly adjusted, it became clear she was unable to tolerate the band and she suffered from dysphagia (difficulty with swallowing) and maladaptive eating patterns.  That meant 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 were not going to perform until she lost substantial weight.

1-877-99-APPEAL

It was nearly too late when she retained our office because she had nearly exhausted her appeals with the payer.  The were denying surgery for reasons 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”

And before you read that language again and think “Geez he must have typed that wrong because that language doesn’t make any sense” I can assure you that is EXACTLY what the policy said.

There are many challenges in cases like these.  Can it really be established that there IS a “complication” even when there is no erosion, slip, obstruction, stricture or other identifiable “technical defect” in the original gastric banding procedure?  Shouldn’t this be challenged based on simple “fairness”?  After all, insurers don’t limit members to one cancer treatment – one knee replacement surgery – one diabetes medication, do they? 

ISN’T THIS PLAIN OLD DISCRIMINATION?????

Well the answer to these questions is YES and so 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 7 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, is accepted and appropriate for her dysphagia and refractory morbid obesity, and is known to be effective for her condition.  He/she 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 co-morbidities but there is no identifiable “complication” which can easily be seen after an UGI or other diagnostic tests.  Something is wrong but it isn’t the kind of complication which is part of some insurer’s non-exhaustive laundry list. . . so they spew this “one surgery” garbage.  Bariatric programs cannot turn away this type of suffering patient based on some pre-conceived notion they can’t get the revision or conversion approved by insurance – – – because it CAN be done and patients needing additional surgical treatment cannot be left behind.

 

  1. Walter LindstromWalter Lindstrom02-25-2013

    Let’s hope you win your appeal and UHC does the right thing. But you should probably line up your options in case they don’t. We should still be able to help. Please call Kelley here at the office (1-877-99-APPEAL) to see how we can help or submit our

  2. Cindy GarnerCindy Garner02-24-2013

    Hello, I have appealed my surgery already. I have united healthcare HMO. Their rules state one Bariatric surgery a lifetime. I had my stomach stapled 24years ago. It has since failed leaving only part of the original stapling. I had an endoscopy showing a interesting hole in my stomach. Kind of like a bridge, that opens to both sides of my stomach. Back then it was called gastoplasty. It was so long ago there are not even medical records to support that I had a procedure. So right now I am awaiting the appeal. I have a feeling the appeal will be denied. Do I still have a chance? Can you help me? Thanks

  3. Walter LindstromWalter Lindstrom01-29-2013

    Hi Ron,
    Sorry to hear you’re going through all that. Tricare can be difficult to deal with. Please call our office (1-877-99-APPEAL) so we can discuss your situation.

  4. Ronald L. HudsonRonald L. Hudson01-20-2013

    I had gastric bypass surgery in 1997, I lost substantial weight but mostly from post-op issues. I keep the weight off sufficient to complete my retirement from the U.S. Army Reserve. I never had dumping syndrome and slowly over a decade and a half I gained my weight back. Within the last two years I went through a complete pre-op nutrition programs, medical exams, etc. Indescope showed that the “stoma” was way too large. I now have my health insurance with Tricare and they will not allow a peer review, even after one appeal on my part. They are adament that one lifetime procedure. I am a resident of Virginia. Please advise.

  5. JanaJana11-06-2012

    I am currently going through the same problem. I am seeking a revision due to partial obstruction and staple line breakdown. Tricare has denied the provider twice saying I have a once in a lifetime benefit. I do not understand since I have mechanical breakdown. Any suggestions?

  6. Regi SchindlerRegi Schindler10-18-2012

    Your a genius Walt! Keep up the good work.

  7. Michele BleechMichele Bleech10-18-2012

    What an excellent case study, thanks for sharing Walter. I think this proves how valuable your service is and speaks volumes of the importance in referring to you as early in the process as possible in order to utilize the course of appeals most effectively.

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