2 years w/sleeve considering D/S

[Munchkin]

LISTEN to these people^^^

 

[Butterfly]

You need to get a copy of your Evidence of Coverage (your actual insurance contract, about 100 pages, that explains coverage and exclusions in DETAIL, as well as the appeal procedures), as well as their bariatric policies. Then you need to figure out which bariatric surgeons they cover.

Teel is gone, and if I recall correctly, good riddance. Siddiqui sounds familiar to me, but I'm not sure how much we know about him.

I found a few links that show my coverage, but I guess I can't post them because I don't have any "likes" yet.

Never, EVER trust what some low level insurance employee tells you over the phone. EVER! They know nothing about bariatric surgery (with rare exceptions) it's all the same to them. They just answer you as fast as they can so they can move on to the next person in the line. No one cares about this as much as you.
Dr. Siddiqui is a vaguely familiar name, though I'm not sure why. If you are interested in him as a potential surgeon, make very sure he does the DS, AND that he does revisions even though revision from sleeve is done by all the DS surgeons I can think of, AND make sure he does the real DS and not something variously called loop DS/aka SADI/ aka SIPS, that is not the same as a DS but some surgeons are calling it the DS. There are strange things that go on in the world of bariatric surgery, and you need to know this and ask the right questions.

I have faxed a letter to the insurance department at Dr Siddiqui's office to see if they've had Caresource pay in the past. A woman over the phone said that they have, but I just want another confirmation.

Their website has a page that details their D/S procedure. I would link to it but I can't post links yet. Their website states this:
Biliopancreatic Diversion With Duodenal Switch (BPD/DS) The biliopancreatic diversion with duodenal switch (BPD/DS) is a combined surgery that makes your stomach smaller and bypasses part of your small intestine for the best-reported, long-term percentage of weight loss. All insurance companies require a BMI of equal to or greater than 35 with co-morbid conditions, or a BMI equal to or greater than 40.


Again, I really can't thank all of you enough for the help you're giving me. If I could describe to you the mental agony I've been in for the last 9 or 10 months, I would. I'm hoping there may be a light at the end of the tunnel that isn't a train.

A million thanks.

 

[Butterfly]

Scratch Dr Siddiqui. The insurance rep just checked with the office manager and he won't do a revision on anyone he didn't do the sleeve on. I guess Mexico will be my option because there are very few D/S surgeons in Ohio.

Edit: It looks like there is a Dr David Schumacher who is with Kettering Bariatrics in Miamisburg Ohio that is on my Caresource list. I will be calling them tomorrow.

On we go.

 

[southernlady]

I would link to it but I can't post links yet

You have to have over 10 posts and then the automatic system that runs in the background has to run AFTER your 10th one for you do post links. We did that to stop spammers. It's a pain to newbies but still a necessary pain.

Here is the link: http://www.premierhealthspecialists.org/phspracticehome.aspx?id=64334
Dr. Maquire was the lead surgeon there when I had my DS cause I looked at that office as an option. Teel was there but he really didn't like doing the DS. Maquire retired, I think about 6 months after I had my DS. I have heard that Dr Siddiqui was doing the DS...and the description DOES suggest the traditional DS.

 

[Larra]

I found the website for Kettering Bariatrics and they don't even mention the DS. They have a chart with lap band (or maybe it was Realize band), sleeve, and gastric bypass, that's it. Their statistics for results with band, btw, are IMHO extremely optimistic. I've read studies where type 2 diabetes was resolved in only 10% with band, they say something like 43%. No way! I could give more examples but that's not the point, the point is that unless their website is out of date, which is always possible, they don't do the DS.

And IMHO Dr. Siddiqui is making a HUGE mistake by not being willing to do the DS on someone who had a sleeve with some other surgeon. There are so many people needing revision from sleeve, we see new ones every week, and we'd see more if they had insurance coverage for revisions, and if they understood that it was the sleeve that failed and not themselves. MO people have lots of experience with failure and lots of experience being blamed for failure, and at some point we internalize all that and blame ourselves. So he's missing out on what could be a very nice stream of income. His loss.

But I digress. By all means check out Dr. Schumacher but I think you will be headed to Dr. Esquerra.

 

[Butterfly]

That makes total sense about spammers, more than fair! It says I've surpassed the minimum # of posts, but that I don't have any "likes" and that's what is holding me back.

Dr Schumacher's info doesn't seem to suggest the loop. When I called my sleeve surgeon's office to get my paperwork sent to me they said they have a new surgeon who does the D/S but upon looking at his info, it is indeed the loop. So thank goodness for Scott warning me!

Since Dr Schumacher didn't appear on the list of surgeons in Ohio that I had, I think I will also call some of the Columbus surgeons just to be sure none of them are offering it too. Dr Schumacher wouldn't be THAT far away at 90 miles, but best to find out.

EDIT: Larra, I can't link to it but for me it's on ketteringbariatrics dot and then under surgery options it's listed as the first one under "surgery comparison"

I agree completely about Dr Siddiqui missing out. I can understand his hesitation, but why not look at my sleeve and data to see if it's something do-able? Oh well.

 

[Larra]

@Butterfly you are right, they do provide an accurate description of the DS. Odd that their comparison chart would leave it off completely. I don't know what to make of that. Let us know when you find out for sure either way.

 

[Jen2016]

@Butterfly - this may be cost prohibitive but I am working with Dr. Keshishian in CA. From everything I've learned on this board and other places, Dr. K is the best of the best. And I may have to do self-pay as well. Dr. K's self-pay cost for everything for an RNY to DS is $28K. So it might be worth checking out his cost for a sleeve to DS. This might be pricey, but it does include 2 years of follow-up care as well. Good luck!!

 

[Butterfly]

@Jen2016 , thanks for the info!

I contacted Dr Schumacher's office and was told that he DOES do revisions and that my Medicaid insurance HAS paid for the D/S with them. Finally, a bit of good news. They said that I need to get my medical records and send them to their office and they will review them and see if I am a candidate. I am going to wait until I meet with my new primary care doctor this Thursday and then send her report along with the paperwork I just got from my sleeve surgeon and hope for the best!

Here is the link to the D/S listed on Dr Schumacher's website: http://www.ketteringbariatrics.com/biliopancreatic-diversion.html

Thanks again for all of the feedback. What a great place this is full of helpful and friendly people!

 

[aaa]

Good to see you're getting the help you need. There's an incredible wealth of info. to be had from the people on this site. @Butterfly

 

[DianaCox]

You're going to need to get clarity on whether Schumacher has experience revising sleeves as well - he's more likely to have encountered that (so many sleeves done, so often they fail ....), but I would like to hear numbers - REAL numbers! - about how many revisions and DSs he's done, since we haven't heard of him as a DS surgeon in the first place.

If it turns out that there is NOBODY in network qualified to do a revision (willing or able to revise the sleeve AND do the DS), you should still be able to request referral to an out-of-network surgeon who IS qualified to do the procedure. The DS is a state of the art procedure, and you should be entitled to be able to choose the best procedure for your medical condition, in consultation with your doctor, even if it is not offered in-network. That is the case with employer-paid HMO plans, and should be the case with Medicaid plans as well.

 

[veronicaj5]

Ok so I had my sleeve "revised" to the DS on July 5th. The first thing I did was call my insurance company and see if it was covered (some of the staff are actually knowledgeable I see you got one at medicaid who wasn't I do not have medicaid fyi) Get yourself a list of bariatric surgeons in your area and find out who is in network, while you are at it also find out what the procedure code would be considered for the surgery. So when you call back to your insurance company you can find out if that code is covered and by which surgeon etc.

 

[Butterfly]

You're going to need to get clarity on whether Schumacher has experience revising sleeves as well - he's more likely to have encountered that (so many sleeves done, so often they fail ....), but I would like to hear numbers - REAL numbers! - about how many revisions and DSs he's done, since we haven't heard of him as a DS surgeon in the first place.

If it turns out that there is NOBODY in network qualified to do a revision (willing or able to revise the sleeve AND do the DS), you should still be able to request referral to an out-of-network surgeon who IS qualified to do the procedure. The DS is a state of the art procedure, and you should be entitled to be able to choose the best procedure for your medical condition, in consultation with your doctor, even if it is not offered in-network. That is the case with employer-paid HMO plans, and should be the case with Medicaid plans as well.

Great advice. I will be sure to request that information from his office. The info I see about him on other boards mostly shows sleeve patients. There just seem to be so few doctors in Ohio who do D/S at all! I'm going to keep researching, though.

Ok so I had my sleeve "revised" to the DS on July 5th. The first thing I did was call my insurance company and see if it was covered (some of the staff are actually knowledgeable I see you got one at medicaid who wasn't I do not have medicaid fyi) Get yourself a list of bariatric surgeons in your area and find out who is in network, while you are at it also find out what the procedure code would be considered for the surgery. So when you call back to your insurance company you can find out if that code is covered and by which surgeon etc.

The procedure code is a great idea! The doctor's office I'm looking a now is the 2nd one who has told me that my Medicaid provider has paid them previously without difficulty for a D/S. Still, I am going to keep looking for other doctors in my state in case this doctor doesn't have the experience.

I live in the largest city in my state and I can't find a single doctor in my city that does the D/S. I'm going to look at doctors at the Cleveland Clinic, too. It's a renowned hospital, certainly they have someone!

Edited: Looking at the Cleveland Clinic's website, they do not offer the D/S. RNY, sleeve, lap band and plication. Ugh!

 

[Larra]

@Butterfly there is one doc at the Cleveland Clinic who has done the DS, but it's definitely not what their group does on a regular basis, and I have no idea where his criteria are, or whether or not he does revisions from VSG (I still think that guy who won't revise someone else's VSG to a DS is losing out, but that's his decision).
Anyway, the doc I've heard of is Dr. Schaur. I might have his name spelled wrong, but I'm close. You may encounter a strong bias towards revising to gastric bypass instead, I don't know, so stick to your guns.

 

[Butterfly]

@Butterfly there is one doc at the Cleveland Clinic who has done the DS, but it's definitely not what their group does on a regular basis, and I have no idea where his criteria are, or whether or not he does revisions from VSG (I still think that guy who won't revise someone else's VSG to a DS is losing out, but that's his decision).
Anyway, the doc I've heard of is Dr. Schaur. I might have his name spelled wrong, but I'm close. You may encounter a strong bias towards revising to gastric bypass instead, I don't know, so stick to your guns.

Thanks, @Larra . I'm just going to keep plugging along until I find the right fit. If all else fails, Mexico it is. Since I can't really do it until May or June 2017 anyway (because of school) it gives me time to research. From what I understand, my insurance requires a 9 month diet so I'll just move forward with that while I try to find someone.