RnY to DS

[Melanie1218]

I just had some good advice from @DSRIGGS about getting approval for RnY to DS with my BMI only being 33. I was 128 lbs until 6 years ago and I am now almost at 200 lbs. I gained back 70 lbs in 6 years. I do have dumping syndrome. I can't have dairy or refined sugar. Has anyone been in a similar situation with a low BMI being an insurance issue to get revision from RnY to DS.

 

[southernlady]

Moving this to the Revision forum.

 

[Larra]

@Melanie1218 it's going to be tough. Not being able to have dairy is not really a complication of gastric bypass. It causes lactose intolerance in many people, as does the DS. So it's not considered a complication, but rather, part of the nature of the operation.
Same for dumping with sugar - that's how dumping works. Not every patient dumps, and we really don't know why some people dump with gastric bypass and others don't, or why for some people it's sugar that causes dumping while for others it's fat, but it's a side effect, not a complication. That is, unless you have abnormal dumping, which does occur occasionally, in which the patient dumps on healthy foods and this causes nutritional problems. But you aren't supposed to be eating sugar after gastric bypass (not being judgmental here, just saying) so if sugar causes dumping, the solution that someone deciding whether or not the insurance company should pay for a revision would tell you is to stop eating sugar.
One of the reasons I think gastric bypass is a flawed operation and could not bring myself to have it is that long term success requires a permanent diet of low fat, low carb and low calorie for life. I knew I would not be able to sustain this forever. I think for many people it's unrealistic. Nevertheless, that's what it takes.
I hope you will be able to get the revision you want, but I think what may prevent approval won't be the bmi of 33, but rather that you don't really have a medical necessity case, unless there is some other reason we don't know about.

 

[Larra]

But I should add here that the bottom line will be in the details of your EOC (Evidence of Coverage) a lengthy document you should get your hands on and read for yourself. It will tell you what your specific policy's criteria for bariatric surgery revisions. I hope you are able to get approval, but some policies are very restrictive.

 

[Kristaz]

@Melanie1218 I was asking these same questions a few months ago. I had an RNY 12 years ago and gained back about 60 pounds or so in the last 7ish years. I had a revision from RNY to DS not quite 90 days ago. My BMI was 29ish. I had my for dumping. While my dumping sounds like it was much more severe than yours I will tell you that through the entire approval process the "severity" of my dumping was not questioned or tested. The DS was a covered revision by my insurance and one of the medically necessary qualifiers was "severe dumping". They had requested medical records from my primary with whom I had maybe discussed the dumping twice then was referred to a gastroenterologist (the ins co didn't ask for his records).

However this is a MAJOR surgery with a ton of risk especially when it comes to the revisions. I had arguably the top revision Dr in the country (Dr. Ara Keshishian) I will tell you initially after the surgery especially because of the feeding tube I thought... Holy shit what did I do to myself. Maybe I should have just lived with the dumping. I am happy with my decision now but sometimes it is still a struggle with protein and vitamins.

Best of luck. If you have any question I am happy to help.

 

[Spiky Bugger]

I just had some good advice from @DSRIGGS about getting approval for RnY to DS with my BMI only being 33. I was 128 lbs until 6 years ago and I am now almost at 200 lbs. I gained back 70 lbs in 6 years. I do have dumping syndrome. I can't have dairy or refined sugar. Has anyone been in a similar situation with a low BMI being an insurance issue to get revision from RnY to DS.

I have no idea, but wanted to welcome you. The only thing I know for sure is that a RnY-to-DS revision is about as tough as it gets. Literally, there are very few surgeons ON THE PLANET I would trust to peform that revision on me.

Sue

 

[Melanie1218]

@Melanie1218 it's going to be tough. Not being able to have dairy is not really a complication of gastric bypass. It causes lactose intolerance in many people, as does the DS. So it's not considered a complication, but rather, part of the nature of the operation.
Same for dumping with sugar - that's how dumping works. Not every patient dumps, and we really don't know why some people dump with gastric bypass and others don't, or why for some people it's sugar that causes dumping while for others it's fat, but it's a side effect, not a complication. That is, unless you have abnormal dumping, which does occur occasionally, in which the patient dumps on healthy foods and this causes nutritional problems. But you aren't supposed to be eating sugar after gastric bypass (not being judgmental here, just saying) so if sugar causes dumping, the solution that someone deciding whether or not the insurance company should pay for a revision would tell you is to stop eating sugar.
One of the reasons I think gastric bypass is a flawed operation and could not bring myself to have it is that long term success requires a permanent diet of low fat, low carb and low calorie for life. I knew I would not be able to sustain this forever. I think for many people it's unrealistic. Nevertheless, that's what it takes.
I hope you will be able to get the revision you want, but I think what may prevent approval won't be the bmi of 33, but rather that you don't really have a medical necessity case, unless there is some other reason we don't know about.

Larra thank you for your response, it's greatly appreciated. I was telling my husband all the long that sugar and dairy was something i was going to be restricted with from day one after the Gastric Bypass. That's why I never complained about it to any Dr's. The only reason I brought it up as an issue was because the surgeon I just saw told me that it was considered dumping syndrome and that was a complication. I never thought it was I knew it was a side effect from the RnY that I'd have to live with. When I had the gastric bypass no other option was ever mentioned and I was told "gastric bypass is a permanent weight loss surgery". It worked I lost 110 lbs in 9 months and kept it off from 2003 til 2010. I slowly began gaining then BAM in 2013 i had put on 30 lbs then by 2016 40 more. All my medical records (Doctors and Hospitals) have NO records. In illinois they are only required to maintain records for 10 years so i have NONE. I will definitely request my EOC but I was told by a rep that my policy does cover WLS including revision based on medical necessity. I am having an upper GI on Tuesday. If that shows my pouch is stretched does that help in my fight to get approved? I am seeing PCP today at 5:30 to request blood work (since I haven't had blood work in a year-and-a-half) plus to tell the Dr i have had dumping all the long (cause that is what the other surgeon had told me I had from the dairy and refined sugars). When I mentioned the dumping to Kristina she said it was important to have that documented with my PCP. She also said to make sure I get a copy (on disk) of the upper GI and mail to her so Dr K can review it. Is there any of things I could use to my advantage to get approved that would be in my favor that i may not be thinking of things that i may think are normal but aren't? I do have severe heartburn and did have to see a gastroenterologist for it. I am also having stomach spasms (in the upper left side where my pouch is). I know you are an expert when it comes to being an advocate per say for us people trying to get our surgeries and insurance turns us down. I had alot of issues for good 5 years post op with B12 and iron. I had to get B12 injections and iron supplements. But the last 8 years my B12 and iron are not an issue probably because i stretched my pouch so much and I am consuming enough now to no longer have to worry about it. I have read about the DS being a very tough surgery. I had a long recovery with the Gastric bypass and was on pureed foods and water for first 11 weeks than a sift diet for 6 weeks then slowly introduced regular foods. I was compliant 100% for a good 2 years. I never ever thought I'd be battling obesity again!!!! I've had 2 major back surgeries cause of the weight gain, bladder issues from weight gain, sleep issues from weight gain. Does any of this stuff make it medically necessary? Not having previous records, is that an issue? Thank you again for your help and input.

 

[Melanie1218]

@Melanie1218 I was asking these same questions a few months ago. I had an RNY 12 years ago and gained back about 60 pounds or so in the last 7ish years. I had a revision from RNY to DS not quite 90 days ago. My BMI was 29ish. I had my for dumping. While my dumping sounds like it was much more severe than yours I will tell you that through the entire approval process the "severity" of my dumping was not questioned or tested. The DS was a covered revision by my insurance and one of the medically necessary qualifiers was "severe dumping". They had requested medical records from my primary with whom I had maybe discussed the dumping twice then was referred to a gastroenterologist (the ins co didn't ask for his records).

However this is a MAJOR surgery with a ton of risk especially when it comes to the revisions. I had arguably the top revision Dr in the country (Dr. Ara Keshishian) I will tell you initially after the surgery especially because of the feeding tube I thought... Holy shit what did I do to myself. Maybe I should have just lived with the dumping. I am happy with my decision now but sometimes it is still a struggle with protein and vitamins.

Best of luck. If you have any question I am happy to help.

Kristaz thank you as well for your input. I appreciate your input as well. We sound alot alike other than I don't seem to have the "dumping" like you do. May i ask how you are feeling? How much weight have you lost so far? How long was it post surgery until you coukd get around and feel better? I've read tons on the malabsorption issues so I'm prepared to do what is expected of me post op (although I know easier said than done). How long total were you in California for surgey? Was dumping the one and only issue you had to get qualifed? (Besides weight gain Thank you again!

 

[Melanie1218]

I have no idea, but wanted to welcome you. The only thing I know for sure is that a RnY-to-DS revision is about as tough as it gets. Literally, there are very few surgeons ON THE PLANET I would trust to peform that revision on me.

Sue

Hi sue, sure sounds like it's a tough surgery but one that will solve many issues i have with being obese. Dr K is my choice for sure now.

 

[Charris]

I think more than likely @Kristaz why you and I had severe dumping is Dr. Juarez did a lot of Distal Rnys . I remember right after surgery he told me he gave me a distal RNY. It didn't mean much then but after suffering from severe dumping I understood. To be honest I was happy I dumped because it kept me away from eating a crap load of stuff that I shouldn't have eaten.

 

[Kristaz]

Kristaz thank you as well for your input. I appreciate your input as well. We sound alot alike other than I don't seem to have the "dumping" like you do. May i ask how you are feeling? How much weight have you lost so far? How long was it post surgery until you coukd get around and feel better? I've read tons on the malabsorption issues so I'm prepared to do what is expected of me post op (although I know easier said than done). How long total were you in California for surgey? Was dumping the one and only issue you had to get qualifed? (Besides weight gain Thank you again!

Hi! Yes. My weight regain wouldn't have qualified me because my BMI was low. It was the dumping that got the approval. I was in California for a about 10 days. Dr Appt the day before surgery - 3 days on the hospital then had 7 day follow up appointment. I was very sore and just wore out probably from
Not eating, pain meds and just general healing. By my 7 day appointment I felt significantly better. Incision/muscle soreness because mine was open, he also had a lot of adhesions to take down from prior procedures. So that probably attributed to the soreness. I was back to work that following Monday on half days in a light capacity. I am a marketing director so not very strenuous. I would say the biggest challenge for me was the feeding tube that Dr K puts in for any revision. It was helpful at first to push pain meds, protein and water when it was still difficult by mouth. After that it was just uncomfortable and sometimes painful.

Day of surgery I was 188 (he did not want me on the pre-op diet since I was a "lightweight") today I am 158. (I am tall 5'9") they do say that revision weight comes off slower. Mine was about 12-15 pounds the first week the I am kind of stair stepping down. I'll lose nothing for 7-10 days then drop 2-3 pounds.

 

[Melanie1218]

Hi! Yes. My weight regain wouldn't have qualified me because my BMI was low. It was the dumping that got the approval. I was in California for a about 10 days. Dr Appt the day before surgery - 3 days on the hospital then had 7 day follow up appointment. I was very sore and just wore out probably from
Not eating, pain meds and just general healing. By my 7 day appointment I felt significantly better. Incision/muscle soreness because mine was open, he also had a lot of adhesions to take down from prior procedures. So that probably attributed to the soreness. I was back to work that following Monday on half days in a light capacity. I am a marketing director so not very strenuous. I would say the biggest challenge for me was the feeding tube that Dr K puts in for any revision. It was helpful at first to push pain meds, protein and water when it was still difficult by mouth. After that it was just uncomfortable and sometimes painful.

Day of surgery I was 188 (he did not want me on the pre-op diet since I was a "lightweight") today I am 158. (I am tall 5'9") they do say that revision weight comes off slower. Mine was about 12-15 pounds the first week the I am kind of stair stepping down. I'll lose nothing for 7-10 days then drop 2-3 pounds.

Thank you so much for the information. I am glad you're feeling well. Sorry to hear the feeding tube cause you some discomfort and pain who did you go to to have the feeding tube removed? Were you dumping from any and all kinds of foods? Who is your insurance carrier if you don't mind me asking. How quickly did you get approved and get into surgery once you are approved? Congrats on the weight loss. 158 sounds like a great weight for your height. When i was 136 i was perfectly happy and heathy i only pray i can feel that way again soon.

 

[Kristaz]

Thank you so much for the information. I am glad you're feeling well. Sorry to hear the feeding tube cause you some discomfort and pain who did you go to to have the feeding tube removed? Were you dumping from any and all kinds of foods? Who is your insurance carrier if you don't mind me asking. How quickly did you get approved and get into surgery once you are approved? Congrats on the weight loss. 158 sounds like a great weight for your height. When i was 136 i was perfectly happy and heathy i only pray i can feel that way again soon.

My insurance was blue cross blue shield of AZ. I dumped on all kinds of foods. Some days almost anything I put in my mouth other days I was fine. Ironically sugar and things that typically caused dumping didn't really trigger it.

After I got all the insurance pre requirements done (nutritionist visit, phy Eval etc) it took them about 2-3 weeks. Dr Ks office was on top off it. I had my surgery the week following my approval as I had a time restriction because my insurance was changing.

I am in AZ so I went for my 6 week follow up and tube removal to DR K. ( however my tube fell out about 2 days before my appt - freaked me out.)

 

[Kristaz]

I think more than likely @Kristaz why you and I had severe dumping is Dr. Juarez did a lot of Distal Rnys . I remember right after surgery he told me he gave me a distal RNY. It didn't mean much then but after suffering from severe dumping I understood. To be honest I was happy I dumped because it kept me away from eating a crap load of stuff that I shouldn't have eaten.

I had Dr Pulowski (who seems to have disappeared off the face of the planet - assisted by another dr who now runs a lap band mill in AZ) at the wish center in Tempe. Back then they were one of the only places I could find that offered weight loss surgery. However I am ashamed to admit that through youth and stupidity I don't have my surgical report nor does the hospital seem to be able to sing records. So I am not sure of much other than what I remember being told about the surgery.

 

[Larra]

Lots of questions here, I'll try to hit the high points.
Yes, get a copy or disc of the upper GI, and ask the radiologist specifically to assess the size of the stoma and not just the size of the pouch. Everyone seems to focus on whether or not the pouch has stretched out and ignore the stoma. In reality, if the stoma has enlarged significantly, it doesn't matter how small the pouch is, everything you eat just falls out of the pouch and into the small intestines, leading to near constant hunger, and, of course, weight gain. This can also cause dumping and reactive hypoglycemia.
Regarding your insurance coverage, never trust what some random employee tells you over the phone. It's crucial to know the specifics of your policy. Even if that person is right that revisions are covered, what type of revisions? Under what circumstances? There are often very specific and more stringent requirements for coverage for a revision than for a primary bariatric surgery, AND you need to know coverage for the DS as well, AND you also may need to know your appeals rights, if any. So get that EOC - no one cares about this as much as you do. And if the policy is confusing, there are people here who can help interpret it, but only if you get it.
Regarding dumping, the milk issue is not dumping, it's lactose intolerance. And we get it with the DS too, so that probably won't change. And most bariatric surgeons believe that dumping is a side effect, and not a complication UNLESS it's like the dumping @Kristaz had where the foods involved were healthy foods (not sugars and/or fat) and impairing her health. If you are having sleep issues, get tested for sleep apnea, because that's a serious comorbidity that could help you get approved for revision, but I really don't think the dumping will do it. But hey, I've been wrong before, and Dr. K will be the one trying to get authorization, not me, so make sure he knows about it and we'll let him sort out how serious it is.
You were told the gastric bypass is permanent. My interpretation of that is that what you may have been told was that the operation is permanent, not the weight loss. Most RNY surgeons tell their patients to consider the operation permanent because it's so difficult to reverse and reversal is so rarely done. But most also tell their patients that if they don't follow the prescribed diet (low calorie, low fat, low carb) they will regain weight.