Question:
2.5 years post op, want a revision - will insurance pay?

I know every insurance company is different. Since day one of my surgery I have never felt that it was done correctly. Now two and a half years later i'm at the same weight I was a year ago. I am 5'6" and started at 260 pounds and am currently at 180-185(it flucuates) I haven't lost a pound for over a year now and I can eat a lot of protein - more than I should, I feel. I've always been able to eat a lot. But what i'm afraid of is that insurance wont cover a revision. Which isn't fair if the doctor didn't do the surgery correctly. On January 19th i'm seeing a different surgeon, i'm hoping he'll help me. I wear a size 14 and feel like a house, I look in the mirror and I see the same person 80 pounds ago, my belly is huge and it depresses me so. No matter how much I exercise, no matter how much carbs I cut, or how much protein i eat or how much water I drink i can't get below 180 pounds. Something is wrong with my pouch I just know it.... Another question is - if there is a staple disruption or something I wonder if insurance will cover it. ARGH the depression and stress of all this is enough to overwhelm a person beyond belief. Anyone else having these same issues? or have been thru this? Thanks in advance to all of you that repsond..... God Bless you ALL!    — Jonna M. (posted on January 7, 2004)

January 7, 2004
Well, unless you can show a mechanical failure (ie: staple line disruption, fistula, etc.), it's almost a guarantee they won't cover it. Even with a SLD, it's a question of them seeing the benefit of approving it now, rather than waiting for you to gain all your weight back. It's a coin toss. Sounds weird, but if you're set on a revision, I hope they find a SLD or some other mechanical problem. Good luck.
   — Leslie F.

January 7, 2004
I am sorry that you are so unhappy. I hate to be pessimistic but at your height and your weight I doubt that any insurance would pay for a revision. And, I doubt that any doctor would do it. I am 5'5" tall and weigh 165 and my surgeon says that I am at the perfect weight. I haven't lost any in a year either and he doesn't want me to lose any more at all. In fact, he wanted me to stop at 190. He say at my ager (grrrrrrrrrr) that I don't need to be any smaller. I did lose about 20 pounds after having my tummy tuck (he removed 5 pounds of skin and flab and I lost the rest after the surgery).
   — Patty_Butler

January 7, 2004
Another question I have is - can you tell you have SLD without tests? Is there pain?
   — Jonna M.

January 7, 2004
Some people will have a recurrence of acid reflux, others will have no symptoms, other than being able to eat more. BUT, we all are able to eat more gradually, as we are further & further post-op. This is perfectly normal. Many people attribute being able to eat excessive amounts and fast weight gain to their own failure, rather than being checked for mechanical failure. These people often feel too ashamed to seek help, and if the surgeon is unwilling to admit to possible mechanical failure, that surgeon is an idiot (I'm being kind). Even those who have been transected may form a fistula (the old stomach falls back in love with the new pouch & forms a tunnel to exhange food & acid). The symptoms of a fistula are often the same as a SLD. Again, this is rare, but it can happen, and it's NOT the patient's fault!
   — Leslie F.

January 7, 2004
It really depends on the insurance company and the problem. You very well may have a SLD or some other kind of issue. Don't beat yourself up over it. I had a SLD thanks to a lovely gastroenterologist and his poking camera. But I also had an ulcer that needed to be removed. I had this ulcer removal and a revision to fix the SLD and didn't even require approval for it. Weighing 155lbs. So it can be done. See this new surgeon, explain to him your concerns, have an upper gi to check for leaks...it may be as simple as that.
   — RebeccaP

January 7, 2004
As for any sign of the SLD...I had none. Not a clue until the surgeon read the report from the scope where the twit poked a hole in the staple line. So sometimes you never even know you have it.
   — RebeccaP

January 7, 2004
Jonna, certainly get it checked out. If there is a mechanical problem with the first surgery, you certainly have a much better chance of getting a revision approved by your insurance company. If there is nothing mechanically wrong, they won't pay for one. If you find that this is the case, perhaps just adjusting your diet somewhat (if you haven't already done so). Such as tracking your daily calorie intake and cutting out a few hundred calories a day for a few weeks to see if that works. Also, if your a 3 meal a day person, switching to 6 smaller mostly protein meals. Also consider trying a different form of exercise (are you doing heart pumping cardio?) Sometimes all our bodies need is to shake up our normal routines to get the weight loss going again.
   — Cindy R.

January 7, 2004
Not everyone feels anything with SLD. Another possibility is a relaxed stoma. Both are mechanical and can be found with a scope. (EGD) I've not seen revisions approved just for stalled wt loss, but I have seen revisions approved for intact surgeries where wt gain is starting. Perhaps you can seek out a doctor who does a lot of revisions (and has seen "everything" and they know how to write a letter for you, as well as correctly dx your problem.
   — vitalady

January 7, 2004
I would do as everyone else has said and get checked out just to make sure there is or isn't a mechanical failure. But if there is not , mybe all you need is to have a TT. You will lose that excess skin hanging there and I have heard from several people that it often jump starts a mini loss of 1-20 pounds. That plus the skin weight would put you really close to your number goal, but more than that it may help you to feel better about yourself so that the number doesn't mean as much.
   — Tricia S.

January 7, 2004
Get on your insurances website and see what they say about covering revisions, or call them on the phone?? Also, After checking to see if SLD (and it turns out to be one) contact Delores Sester or Michelle Curran or others on this board that have had revisions to see how they got theirs approved? Hope this helps!!
   — bufordslipstick

January 7, 2004
DUH!!! I meant to say TRANSECTION, I think. Some people on this board (that I mentioned prev) had rny's with SLD and then got TRANSECTED, (which is the best kind of gastric bypass). I didn't notice my mistake till I read another question on here kind of about the same thing.
   — bufordslipstick

January 7, 2004
My insurance paid when it was discovered I had a SLD. I went from a VBG to an RNY. It depends on their criteria, I think some will apply the BMI rules even with a repair/revision and if yours is that way, they will not approve you until you gain back enough to hit a 35-40 BMI. I would call and ask them about covering repairs. If they cover other complications after the original surgery, I can't see why they wouldn't cover this complication.
   — Ali M

May 26, 2005
I dont have an answer for you but when i read your posting it was like i had written it myself...i have the same story and same questions....have u had any luck yet?
   — Kari N.

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