the beginning of trying to get approved

[Ellen Harry]

After a lot of thought I have decided to see if I can be approved for an RNY to DS revision. My RNY was in nov 2008. The surgery failed me and I failed as well. I am only 60 pounds down and weigh in at 300 lbs. I wanted to get DS back in 2008 but it took 2 years to get approved so I just wanted to do something.

Getting an approval will not be easy as my insurance policy has the one surgery per person per lifetime clause. I will be requesting the printed policy so that I can find out the specifics but still plan to move forward regardless of that stipulation.

I have some discomfort in the area of my pouch that suggest there is something wrong. Can anyone tell me if they think it would be wise to see a GI doctor and have some imaging done to see if there is any problems prior to contacting the surgeons office?

As for surgeon, my initial hopes are to see dr kemmeter in grand rapids. I have read on several forums that he is performing the rny to ds revision. I will research more about number of surgeries he has performed, if it is open vs lap, etc.

I am not excluding the thought of revising my current RNY but I do not think that is the right decision for the amount of weight I need to lose and long term results.

So I am pretty overwhelmed and not necessarily sure what to do right now. I more or less just finally decided it was time to take some action.

Thanks for reading

 

[newanatomy]

Hello and welcome. I am sure there will be people along shortly to advise you regarding your revision. Good luck.

 

[JuliaDS]

Welcome @Ellen Harry.

I'm not a revision but wanted to say hi. You'll find a wealth of quality information and genuine support here. Look forward to following your journey.

 

[DianaCox]

Hi Ellen - let's see what your Evidence of Coverage (EOC) says first. And Kemmeter is one of the surgeons that I have heard does RNY to DS revisions, from one of his patients (who doesn't post here), but to be honest, I've never "met" one on-line. So I don't know how valid that recommendation is. So that is going to take some further research.

 

[Larra]

Hi and welcome!
Get your EOC as @DianaCox says, but if you are having problems from your RNY, a work-up is a good idea. It might be possible to get a revision based on some kind of anatomic complication related to your old RNY. Even if not, if you do end up having surgery, your surgeon needs to know what anatomy he is working with.
Also, if your insurance has an iron-clad exclusion for revisions or some other barricade, keep in mind that you may be able to change insurance in the fall during open enrollment, depending on what else is available to you.

 

[hilary1617]

Hello and welcome @Ellen Harry ! Wishing you all the best on your journey!

 

[southernlady]

Welcome @Ellen Harry

 

[DianaCox]

@Larra - I recommended to her privately that she NOT get a work-up from a GI doc, but rather from a revision DS surgeon him/herself - the GI doc may miss the problem, and then you have the issue of having a record from one doc saying there's nothing wrong, and the DS surgeon has to overcome that hurdle as well - we've seen that a lot lately. I think she should wait for the DS surgeon to do the UGI, which they often prefer to do themselves anyway.

 

[Larra]

Very good point, @DianaCox ! Though it does mean she will be going for the consult with potential DS surgeon without prior approval or denial, thus will probably have to self-pay for the consult. Unless you have a suggestion to get around that?

 

[DianaCox]

Depends if her insurance requires a referral or not, and whether the surgeon is in-network or not. She can ask her PCP for the referral if necessary, and explain to the PCP that she is asking for a specific surgeon because the surgery is very specialized and she has already researched the few options who are qualified to do it.

 

[Charris]

Welcome @Ellen Harry I am one of the few RNY to DS members of the group. Good luck you definitely came to the right place to get the best free advice their is, especially with insurance issues. Diana and Larra are the best.

 

[Ellen Harry]

I made the call to the surgeon's office to find out what the criteria for consideration is. There is an intake appointment that is $250 and insurance will not cover. My husband is requesting the copy of the policy but since I was curious to find out I called the insurance company myself.

The customer service woman was not able to see in the details of the policy anything regarding one surgery per person like the brief description notates. She read it line for line and asked a coworker if she was familiar with it. So I hope that means good news.

The policy did not say anything about how a revision would be handled. She said the only way to find out is to submit the determination of benefits. I am hoping to go to Dr. Kemmeter's office before summer is over and then go from there.

Each revision is taken on individually at his office. If they don't feel comfortable doing a RNY to DS then I will have to think about whether to seek a surgeon out of state since it will be more money. I have a midwest only insurance company so the california doctors are not in network. I am certainly not counting the idea out by any means though.

Thank you for the responses!!

 

[DianaCox]

Most insurance plans have exceptions that allow/require that they cover out-of-network doctors when there is no in-network score qualified to provide a medically necessary treatment. And since the DS is a standard of care procedure, you should have access to a qualified RNY to DS surgeon if they will cover a revision.

 

[Larra]

It's great that you are making the calls and learning more, but you still need to get your hands on the EOC and read it for yourself. A random customer service employee may or may not give you accurate information. We have seen many times where people call twice and get different interpretations of policy from different employees. Remember, no one cares about this as much as you do, there are just there to answer the phone.

They also may be reading from a simple summary of benefits, which lacks the details of the EOC that really matter.

 

[Joyouslyme]

Welcome and here's to getting a speedy approval!