My First Post

[ShmittyInVegas]

Starting the process of getting bariatric surgery (either RNY or DS) and here are a few things:

1. I live in Las Vegas, a 35 years old male, with a BMI of 56 (395lbs, but want to get down to 220lbs) with comorbidities of: moderate obstructive sleep apnea, high blood pressure/hypertension, acid reflux and pain in some of my joints on occasion.

2. I haven't had any health coverage till about November or December so I don't have any medical records to use that will help me get approved by my insurance (Amerigroup Medicaid at the moment but requested a switch to Health Plan of Nevada Smart Choice (Medicaid) since they have only a 3 month period vs 6 with Amerigroup). All I really have are past gym memberships and maybe reciepts from my two months of Nutrisystem from this past summer. Wondering what kind of uphill battle I face in getting approved since I only have recent records to go off of.

3. Getting the gastric bypass though I would like to consider DS. None of the surgeons in my area (Las Vegas) have DS listed on their websites, so I am not sure if it is an option with any of the local surgeons, since they don't have it listed on their websites?

Anyways, I'll have lots of questions as I have my first meeting next week with my likely surgeon (unless I decide to go with a different surgeon).

 

[BebeZed]

Welcome @ShmittyInVegas! I urge you to research the possibilities of the DS as opposed to RNY because the DS is a vastly superior surgery with a much better long-term success rate. Please ask as many questions as you want and take advantage of the vast wealth of knowledge and help available here.

 

[ShmittyInVegas]

How do I find a surgeon here in Las Vegas that performs it that also accepts Health Plan of Nevada or Amerigroup? If they don't have it listed on their website, does that mean its not an option?

 

[BebeZed]

I am not an insurance expert by any means - in fact, I had to self-pay for my surgery. BUT, we do have a couple of very knowledgeable veterans here such as @DianaCox and @Larra who I am sure will weigh in when they see your question.

But generally, if it's not on a surgeon's website, they don't do the surgery. And you don't want just anybody doing the DS because it's relatively complicated.

 

[BebeZed]

Also, I want to let you know that no matter what your decision is regarding surgery, this is a wonderful place for support so please stick around

 

[ShmittyInVegas]

Self-pay or having the surgery out of network isn't an option for me, so its looking like I'm stuck without DS as an option? Or do I need to look at other surgeons in other parts of the state?

 

[ShmittyInVegas]

Thank you!

 

[ShmittyInVegas]

Also, Health Plan of Nevada covers DS which is odd since no surgeon in Nevada performs it?

 

[BebeZed]

Self-pay or having the surgery out of network isn't an option for me, so its looking like I'm stuck without DS as an option? Or do I need to look at other surgeons in other parts of the state?

I am not sure if there are any vetted DS surgeons in Nevada, but don't give up hope just yet because TBH I am still very new at this (I had my DS last October) and I have not yet committed to memory the surgeons and where they are located. Before you arrive at any conclusions, please wait to hear what the other more experienced members have to say. I do know that they'll want to know about your coverage - you will need to have your evidence of coverage (EOC), which is a rather lengthy document that states exactly what the insurance will cover and what it won't. There may be a way to work with the insurance depending on what the EOC says.

 

[ShmittyInVegas]

If I get approved for my request to switch from Amerigroup to Health Plan of Nevada, this outlines their requirements and what they cover SUR043Bariatric Surgery715 (9).pdf

 

[southernlady]

Welcome, @ShmittyInVegas
I'm not aware of any surgeon in Nevada doing the DS. With that said, I would have stayed fat before getting the RNY.

 

[DSRIGGS]

Self-pay or having the surgery out of network isn't an option for me, so its looking like I'm stuck without DS as an option? Or do I need to look at other surgeons in other parts of the state?

No that isn't true. I traveled from Illinois to California for a revision to fix my ds. My insurance covered it and even if you think yours won't there are things you can do to find out for sure. Larra and Diana can guide you through that process... They have helped numerous people who thought they couldn't get covered actually get insurance to cover their is.

You don't want an RnY.... They just don't work and the DS does. I have a friend who had an RnY 25 years ago and he probably weighed close 700 pounds. He lost to 250 and when his stomach stretched back to full size he ballooned back to well over 500. He is just one of many.

Research hard and talk to these ladies as they can help you.

 

[DianaCox]

1) There are NO DS surgeons in NV.

2) DS is a standard of care procedure.

3) You have the right to a second opinion (assuming you must see an in-network surgeon first, and that that surgeon will only recommend something he knows how to do), including the right to get the second opinion from an out-of-network surgeon who can do the DS.

4) Even though you have that right, your insurance company will deny your request for it, so be prepared to self pay for a consult ($300-500) with a qualified DS surgeon (you will appeal the denial of that self-pay too) in order to get a letter of medical necessity saying the DS would be better for you than whatever the in-network surgeon recommends.

5) With the LOMN in hand, you will request a referral to the DS surgeon, which will be denied.

6) Then you will appeal and be denied again.

7) Then, having exhausted your internal appeals (which you have to do first), you will exercise your right to INDEPENDENT Medical Review, which is where you should get an objective review.

 

[ShmittyInVegas]

1) There are NO DS surgeons in NV.

2) DS is a standard of care procedure.

3) You have the right to a second opinion (assuming you must see an in-network surgeon first, and that that surgeon will only recommend something he knows how to do), including the right to get the second opinion from an out-of-network surgeon who can do the DS.

4) Even though you have that right, your insurance company will deny your request for it, so be prepared to self pay for a consult ($300-500) with a qualified DS surgeon (you will appeal the denial of that self-pay too) in order to get a letter of medical necessity saying the DS would be better for you than whatever the in-network surgeon recommends.

5) With the LOMN in hand, you will request a referral to the DS surgeon, which will be denied.

6) Then you will appeal and be denied again.

7) Then, having exhausted your internal appeals (which you have to do first), you will exercise your right to INDEPENDENT Medical Review, which is where you should get an objective review.

I'm as lost as an easter egg... lol. How long will this process take? There's no way I could cash pay, I'm barely scraping by as it is. Would I need to find a doctor in a state that will do it and then go through that process of getting my medicaid to cover it? Feel like I'm drinking out of a firehydrant, lol

 

[ShmittyInVegas]

Tried to send Diana a PM but it looks like I don't have enough posts yet? If it takes getting the surgery in California, I'll do it.