What Are “Revisions” and “Conversions”?
One of the more challenging areas for patients and providers when dealing with insurance denials is in the context of revisions/conversions. While you would think payers would be required to pay for medically necessary treatment because of complications, especially if they are serious or potentially life-threatening, that isn’t the case. Many insurance plans try to “blame the patient” because another surgery is required. They will claim that the patient was not “compliant” with the follow-up program and so it is their “fault” that more surgery is needed. What they are saying, in essence, is that the patient simply isn’t worthy.
THEY ARE WRONG!
Here are common denials we fight and overcome in the context of conversions and revisions:
Only One Surgery Per Lifetime Is Covered
No Proof Of A “Technical Failure” In The First Surgery
Patient Was Not “Compliant” After First Surgery
Patient Is No Longer “Morbidly Obese” And Therefore Criteria Is Not Met
Will Approve Removal Of Gastric Band But NOT Approve Another Procedure To Replace It
There are many reasons why a surgeon might tell you a second procedure is medically necessary, either to “fix” the first (revision) or “replace” the first (conversion). Examples include:
Slip (Prolapse) of an Adjustable Gastric Band
Insufficient Weight Loss