Bariatric surgery is a significant step toward improved health and wellness for individuals struggling with extreme obesity. However, in some cases, patients may not sustain long-term weight loss or may experience complications from their initial bariatric procedure. In such instances, revision bariatric surgery may be considered. This article delves into the complexities of revision bariatric surgery and, more importantly, addresses the critical question: Will insurance cover revision bariatric surgery?
Understanding Bariatric Revision Surgery
Bariatric revision surgery is an additional surgery performed on patients who have previously undergone at least one bariatric surgery. The need for revision surgery can arise from various factors, including complications from the initial surgery, insufficient weight loss, or weight regain. Penn Medicine bariatric surgery and weight management team are experts at bariatric revision surgery.
Reasons for Revision Surgery
Several factors may lead to the necessity of revisional bariatric surgery:
- Complications: The most common complications necessitating revision include ulcers, pouch enlargement, or the loosening of a LAP-BAND. More than 10 percent of LAP-BAND procedures require revision within two years.
- Poor Weight Loss: Patients may qualify for revisional bariatric surgery if they experience poor weight loss after their original procedure.
- Weight Regain: Weight regain after initial success is another reason for considering revision surgery. This can occur due to the stretching of the stomach pouch or stoma over time, leading to overeating.
Candidacy for Revisional Bariatric Procedure
Individuals who experience complications, poor weight loss, or weight regain after their original procedure may be candidates for revisional bariatric surgery. It's important to note that you don't need to have your original bariatric surgery at Penn Medicine to qualify for revisional surgery with their bariatric surgeons. A surgeon will determine the best surgical approach for each individual case.
Expected Results from Revision Surgery
It's important to have realistic expectations regarding the outcomes of revision surgery. Most people lose less weight after a revision than after their original surgery, but results vary depending on the prior bariatric procedure. For instance, many people who don’t lose significant weight with a LAP-BAND experience weight loss after a revision to the gastric bypass. Follow-up care is crucial for recovery and long-term weight loss from any bariatric procedure.
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The Crucial Question: Will Insurance Cover Revision Bariatric Surgery?
Health insurance coverage for revisional procedures varies and is determined by your insurance provider and your plan. The coverage details and requirements can differ significantly from plan to plan and may depend on your medical history or the type of procedure you are interested in.
Factors Influencing Insurance Coverage
Several factors influence whether an insurance provider will cover revision bariatric surgery:
- Medical Necessity: Insurance companies typically consider revision surgery to be medically necessary when it is required to correct complications from the original surgery or to address a failure of the initial procedure to achieve adequate weight loss.
- Compliance with Original Surgery Requirements: Insurance providers may question whether the prior surgery actually failed or if the patient was simply not compliant with the requirements of the first surgery.
- Pre-operative Testing: Having pre-op testing, such as an MRI, CT scan, or endoscopy, to prove allegations of pouch stretching, staple line failure, band slippage, or bypass failure is crucial.
- BMI and Co-morbidities: Insurance companies may consider your body mass index (BMI) and any existing co-morbidities (such as diabetes or hypertension) when determining coverage.
- Original Criteria for Bariatric Surgery: Even if your revision is medically necessary, most insurers require that you still meet the original criteria for bariatric surgery.
- Documentation: Documenting your claims is essential. This includes providing medical records, operative reports from your original surgery, and letters from your surgeon and other healthcare professionals.
Steps to Take When Seeking Insurance Coverage
Navigating the insurance approval process for revision bariatric surgery can be challenging. Here are some steps to take to increase your chances of obtaining coverage:
Understand Your Insurance Policy: Carefully review your insurance policy to understand the specific coverage details, requirements, and exclusions related to bariatric surgery and revision procedures.
Consult with Your Bariatric Surgeon: Work closely with your bariatric surgeon to determine the medical necessity of the revision surgery and to gather the necessary documentation to support your case.
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Gather Supporting Documentation: Compile a comprehensive paper trail that clearly supports your case. This should include:
- Operative report from your original surgery
- Medical records confirming complications or weight loss failure
- A letter of medical necessity from your bariatric surgeon
- Nutritionist or dietitian notes
- Food and supplement tracking records
- Support group participation or behavioral therapy records
Meet the Original Criteria for Bariatric Surgery: Ensure that you still meet the original criteria for bariatric surgery, such as BMI and co-morbidity requirements.
Demonstrate Compliance with Post-operative Recommendations: Provide evidence that you followed the rules after your original surgery, including adhering to dietary guidelines, attending follow-up appointments, and participating in support groups or therapy.
Obtain Pre-authorization: Obtain pre-authorization from your insurance company before undergoing revision surgery.
Appeal a Denial: If your initial request for coverage is denied, don't give up. Review the denial reason carefully, strengthen your documentation, and file an appeal.
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The Role of Your Bariatric Surgeon
Your bariatric surgeon plays a crucial role in making your case to the insurance company. They can provide a letter of medical necessity that outlines:
- Your medical history and previous surgery details
- The reasons why you need the revision procedure
- The expected benefits of the revision surgery
Navigating the Approval Process
Every insurance company has its own approval process, and understanding yours can save you time, stress, and unexpected denials. Be prepared for a waiting period for review, which can take anywhere from a few days to several weeks.
Common Reasons for Denial
Even well-prepared requests can be denied. Common reasons for denial include missing information, timing (e.g., not enough time has passed since your first surgery), or disagreement about medical necessity.
Appealing a Denial
If your request is denied, don't lose hope. Approximately 25% of patients considering bariatric surgery are denied insurance coverage as many as three times before finally being approved, and it can be even more difficult to get approval for a surgical revision.
To appeal a denial:
- Review the denial reason carefully.
- Strengthen your documentation with updated imaging, more detailed clinical notes, or new letters from your surgeon or dietitian.
- Have your surgeon request a peer-to-peer review, if allowed by your insurer.
Appeals take patience, but many people are approved the second or third time around.
Non-Surgical Revision Options
Not everyone qualifies for a second bariatric surgery, and even when they do, the risks, recovery time, and insurance hurdles can be overwhelming. In such cases, non-surgical revision options may be a viable alternative.
Types of Non-Surgical Revisions
Non-surgical bariatric revisions are performed using a flexible scope inserted through the mouth, meaning no incisions, no scars, and a much shorter recovery time. Two common non-surgical revision procedures include:
- SIS (Sleeve-in-Sleeve): Designed for patients who’ve had a gastric sleeve, this revision procedure uses endoscopic sutures to tighten a stretched stomach.
- TORe (Transoral Outlet Reduction): This is used for gastric bypass patients whose pouch or outlet has stretched over time.
Benefits of Non-Surgical Revisions
Non-surgical revisions offer several potential benefits:
- Fewer complications
- Faster recovery
- No hospital stay
- Lower costs (as they are often self-pay options)
Specific Revision Procedures and Insurance Coverage
Gastric Band Revision
There are a number of reasons why a Lap Band patient might need a revision surgery including lack of weight loss, weight gain, or a Lap Band not staying in place. If you are experiencing band slippage, acid reflux, or esophageal issues, your Lap Band may need to be removed. There are several options for Lap Band revision, including repositioning the band. Patients will often find success by converting to another type of bariatric surgery, such as band to gastric sleeve surgery, band to gastric bypass surgery, and band to duodenal switch surgery.
Gastric Sleeve Revision
One of the most common issues facing those who start gaining weight after their Gastric Sleeve surgery is a stretching of the stomach that requires a Gastric Sleeve revision. The first step in Gastric Sleeve revision surgery is determining with your bariatric surgeon which procedure will best optimize your weight loss. If you have a stretched out sleeve, it might be as easy as a resleeve. If you haven’t reached your weight loss goals or are experiencing frequent acid reflux, you might be a candidate for Gastric Sleeve Revision.
Gastric Bypass Revision
For some patients, the stoma created during Gastric Bypass surgery can stretch over time, which can lead to overeating and weight gain. For many patients with a stretched stoma, the gastric bypass revision can be achieved with a minimally invasive procedure. Texas Laparoscopic Consultants offers a non-surgical gastric bypass revision procedure that is performed endoscopically. The surgeon uses the endoscope to place stitches around your stomach outlet and around the stomach pouch to reduce the capacity to a size similar to its original post surgery capacity.
Duodenal Switch Revision
A small percentage of Duodenal Switch recipients need revisions generally due to extreme weight loss or malnutrition. While revisions for this procedure are rare, it is important to contact a bariatric team if you are experiencing complications from your Duodenal Switch surgery.
Finding an Experienced Surgeon
If you have one of these concerns, having an experienced surgeon evaluate your condition is very important, as revision weight loss surgery can be challenging and requires advanced skills and techniques. Look for a surgeon and center with accreditation from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).