Hello all and help with Kaiser!!

[DianaCox]

You should be aware of how negatively and hyperbolically you exaggerated what I said - these words are not what you said they were:

“You are going to have to be a lot more emotionally intelligent than stating you can't handle waiting 6 months.”
“If you can't stand up to this, perhaps the DS is more surgery than you can handle.”
“Many of us think that access to the DS should require an IQ test and an Emotional Intelligence test.”

Nobody said that you are “stupid and retarded emotionally.” You could read it that way, by marinating it in your own stew of issues, but that’s NOT what was said.

But whatever it takes to get your loins girded for the battle with the insurance company, and the many fights you’re going to have to engage to keep yourself healthy living with the DS for the rest of your life. It’s not fair or right for people to go into this surgery without an appreciation and commitment forcwhat is going to be required of them.

But the vast majority of us would tell you it is very much worth it.
~~~~~~~~~
Grilled marinated lamb chop and seasoned buttery roasted potatoes for dinner. I might steam some yellow squash and drown them in butter and salt too. There’s 5/6ths of a key lime pie in the fridge, but I’m not feeling like having pie tonight. Maybe I’ll slice and lightly sugar the strawberries, whip up some fresh whipped cream and put some of each into one of the premade shortbread shells I bought. Depends on how I feel in 3 hours or so. I still eat multiple small meals per day at 15 years out.

 

[michelle vasey]

And you might consider how what you said and then reaffirmed might be taken by someone who is in a vulnerable condition. “Many of us think that access to the DS should require an IQ test and an Emotional Intelligence test.” and then saying I am not ready or worthy came across as that.

Anyway, I have tried before and would like to move on. We had a bad bit, lets move on. It did kick me in the ass, it just also kicked me in the heart. I have a phone call with the bariatric surgeon in about an hour. I am going to let him know I think the DS will be the best for my long term health. I have a predisposition for diabetes (my dad is a diabetic with only 12% of his kidney function left) and he is also obese. I think for a lifetime of health, this is the best option. I do not want to get the sleeve and then have to have a second surgery for the DS. That seems wasteful and unnecessary surgically. I also think biliopancreatic diversion is a good idea. Any thoughts on these items?

 

[Larra]

michelle vasey , the danger of a phone call (and I realize it was their suggestion, rather than just issuing the denial via email) is that you can easily get tripped up, especially if you don't know your facts about the different procedures well. I say this because of your question - biliopancreatic diversion IS the DS. DS consists of the sleeve plus biliopancreatic diversion.

I fully support your decision to have the DS and agree with you that it far and away your best option for your long term health. But you are going to have all kinds of difficulty with Kaiser if you get your facts wrong at all, because they are going to document in your chart that you were not well educated about this procedure and then they will throw their documentation at you at all levels of appeal. Keep it simple on the phone, review the details of the operations so you know what you're discussing, and do your best. And stick to your guns.

 

[DianaCox]

And get any response in writing or you can’t use it to appeal!

 

[Diana S.]

But you are going to have all kinds of difficulty with Kaiser if you get your facts wrong at all, because they are going to document in your chart that you were not well educated about this procedure and then they will throw their documentation at you at all levels of appeal. Keep it simple on the phone, review the details of the operations so you know what you're discussing, and do your best. And stick to your guns.

Can confirm.

I also strongly believe that I dropped the DS card too soon in my case, and should have probably waited until I was approved for surgery to specify which kind I wanted and was best for me. Unless your BMI is over 50 (or over 60 in the example of my so-and-so Kaiser bariatric surgeon) they are going to fight you tooth and nail. If you have an "all ahead go" and then they are only denying you because they don't want to shell out the dough for the DS (a standard of care procedure that they DO cover), then you may have a much stronger case in your appeals. In my case, I had to fight the reasoning that I was only approved for the RNY to combat GERD and otherwise they didn't think a WLS was medically necessary, and because the DS only makes GERD worse (it doesn't and in fact I am heartburn free since surgery!) it is inappropriate for me. Those were fun letters to write.

 

[Diana S.]

Also, I am deathly curious about how your phone call goes, so please update if you are inclined!

 

[michelle vasey]

Thanks all!! It sounds like I should move forward with getting approved for the sleeve (I am down another 2 lbs, thank you very much) and then put in my request for the DS? Any other thoughts? And thanks again for the pointers.

I wonder if I can tell him I am moving forward with the sleeve but still requesting the DS?

 

[DianaCox]

BPD also refers to the discredited Scopinaro procedure, which is the switch plus a large gastric pouch and REMOVAL of the distal portion of the stomach and proximal duodenum including the pylorus. It is completely outdated, not covered by insurance - and is NOT reversible or convertible to any other procedure. If you don’t know this, you are going to prove to Kaiser that you are not knowledgeable enough to request the DS.

 

[Larra]

Actually, you can use a verbal denial to start your internal appeals. You would just need to document in your appeals letter that you spoke by phone with Dr. X on such and such a date and he refused to authorize the DS for you. But you DO need to pin Dr. X down, as sometimes they will not quite state a denial, and instead go on about how you can do just as well with gastric bypass or sleeve (not true, but may be said) or too high risk, or some other thing, and not come right out and say no.

If you just can't pin the doc down, you will need to do a follow-up email, reference your conversation, politely say that you respect his opinion but you still believe the DS will give you the best possible results and again make a specific request for authorization.

 

[Larra]

Instead of saying you are moving forward with the sleeve, I would say you are working hard to meet all of Kaiser's pre-op requirements, and at the same time you have been doing your research about all the standard of care procedures and are requesting the DS because it has the best long term results for percentage excess weight loss and for maintenance of that weight loss of any bariatric surgery, and also for permanent resolution of your comorbidities (assuming you have comorbidities, I can't remember).

 

[michelle vasey]

Hi guys,

I just completed the phone call with Dr. Mostaedi. We went through the 3 bariatric procedures including the sleeve, the bypass and the DS. He felt the DS was the most radical procedure and here are his points:

Higher surgical risk
Higher healing risk
Higher risk of long term vitamin and iron deficiency
BMI 37 not recommended because of higher risk
DS is only done .5% of all bariatric surgery because of the much risk to the long term health of the patient.

He said Kaiser Richmond would never recommend the DS for me because of the high risk of me becoming underweight and severly malnurished. I asked what the next step would be if I still felt it was the right procedure for me. He said he would have to refer me a to secondary bariatric program for a second opinion. Either Fremont, S. SF. If they concurred with him (I'm sure they would) then I would have to issue a complaint to Kaiser to move forward. He strongly urged me not to risk my health with this procedure.

 

[Diana S.]

Hi guys,

I just completed the phone call with Dr. Mostaedi. We went through the 3 bariatric procedures including the sleeve, the bypass and the DS. He felt the DS was the most radical procedure and here are his points:

Higher surgical risk
Higher healing risk
Higher risk of long term vitamin and iron deficiency
BMI 37 not recommended because of higher risk
DS is only done .5% of all bariatric surgery because of the much risk to the long term health of the patient.

He said Kaiser Richmond would never recommend the DS for me because of the high risk of me becoming underweight and severly malnurished. I asked what the next step would be if I still felt it was the right procedure for me. He said he would have to refer me a to secondary bariatric program for a second opinion. Either Fremont, S. SF. If they concurred with him (I'm sure they would) then I would have to issue a complaint to Kaiser to move forward. He strongly urged me not to risk my health with this procedure.

Oh, what a giant pile of bull-hockey! It's a much more complicated procedure that requires a knowledgeable and experienced hand, and there just aren't that many surgeons that meet the bar. It's a lower percentage of bariatric surgeries because NO ONE talks about it, and everyone gets bullied into other procedures. The higher risk of deficiencies is if you biff your supplements and blood work. Smaller BMIs do just FINE with the DS, and there are plenty of people here doing just that. You're not going to turn into a twig and die of being too skinny.

Ask that he refer your request to his superior (probably Dr. Dutta, the regional chair), and get that denial in writing (email or paper). Use that to file a grievance with Kaiser about access to a standard of care procedure that is covered for your diagnosis. If you qualify for a gastric bypass or a sleeve, then you qualify and are about the same risk for the DS. There are NIH criteria that you probably have met, including a BMI of 35 w/ comorbities (you have diabetes, I think I read?), and not Kaiser's "I don't wanna" attitude.

 

[southernlady]

Hi guys,

I just completed the phone call with Dr. Mostaedi. We went through the 3 bariatric procedures including the sleeve, the bypass and the DS. He felt the DS was the most radical procedure and here are his points:

Higher surgical risk
Higher healing risk
Higher risk of long term vitamin and iron deficiency
BMI 37 not recommended because of higher risk
DS is only done .5% of all bariatric surgery because of the much risk to the long term health of the patient.

He said Kaiser Richmond would never recommend the DS for me because of the high risk of me becoming underweight and severly malnurished. I asked what the next step would be if I still felt it was the right procedure for me. He said he would have to refer me a to secondary bariatric program for a second opinion. Either Fremont, S. SF. If they concurred with him (I'm sure they would) then I would have to issue a complaint to Kaiser to move forward. He strongly urged me not to risk my health with this procedure.

My BMI was a whopping 35.2. No higher risk.
Vitamin and iron issues are handled by being extremely educated and aggressive about vitamins and labs.
You are morbidly obese, you automatically have a higher surgical risk, applies to ANY weight loss surgery.
Only higher healing risk also applies to ANY weight loss surgery.

Don’t agree to any particular surgery. Just agree to start the process.

Btw, my first surgeon told me I was too small for the DS, I would lose too much weight. I called horseshit and fired him.

My lowest was 121 for 10 seconds (a 21 BMI), I’ve maintained between 140-145 for the last four years now. A 24.8-24.99 BMI. Too low, horse shit!

 

[Larra]

Your bmi is 37...NOW, right? But it was higher when you started the process and began the mandatory weight loss (which is just an unnecessary barrier to medically necessary health care, but nevermind that for now). Nice how he used the lowest weight he could find.

I don't think anyone can force you to have a second opinion discussion with another bariatric surgeon if you don't want to do it. We all know how that's going to go. You can instead email again and say that even taking his opinions into consideration you still want the DS because of its well documented superior results (or you don't even need to give your reasons in your email) and request either authorization or a denial. The second opinion thing is only going to delay you.

Regarding some of his specifics - as Diana S. said, there are reasons the Ds isn't done more that have nothing to do with it's risks, rather, it's because surgeons choose instead to only do quicker, easier procedures (and often don't even let patients know of the existence of the DS, which is a failure of informed consent), because some insurers don't cover it, or only for higher bmi's, and people either don't know their appeal rights or aren't up for the fight. The bit about nutritional deficiencies is very misleading - there are excellent studies of large groups of patients that show the rate of problems is actually very low, and usually due to noncompliance. And then, some surgeons give such bad nutritional advice that problems are almost inevitable, which is the fault of the surgeon and not of the operation. And regarding surgical risks - not true! If you only do the DS on the heaviest, sickest patients, or course your complication rate will be higher. There is an excellent study from the University of Chicago group with compared gastric bypass vs DS complications rates with all patients having bmi over 50 and similar comorbidities. Guess what - the complication rate was the same, but the DS patients lost more weight and had better resolution of comorbidities. And higher risk of healing problems - I've never even heard that one before!

Strange how he didn't bother to note the superior results of the DS for permanent weight loss and permanent resolution of comorbidities. Only the potential negatives.

It's your decision about the second opinion piece. Given that the bariatric surgery programs at all the NorCal facilities meet together and set the same policies for the whole region, there is no way you are going to hear anything different.

 

[Larra]

Oh, and didn't I tell you the surgeon might fail to give you the denial? I rest my case.