A little about me....

Annemarie

Member
I feel like I've reached the point where bariatric surgery (specifically - duodenal switch) is something I want to seriously consider.

I've been heavy pretty much all my life. I come from sturdy peasant stock. :) Until recently, though, it was mostly just a number on the scale. Now, I have some comorbidity to go along with it.

I'm 5'4" and weigh 234 lbs. My BMI is 40.2. If the "ideal weight charts" are to be believed, I have 114 lbs to lose. (although I will say that at 120 lbs I look emaciated; i've seen the pics of the brief time that was my weight. I really feel better at 20 lbs higher than the lowest ideal weight....so 140 would be fabulous....and it's hard to even imagine it)

In a nutshell here are the health issues causing me to seriously consider WLS:
  1. I was recently diagnosed with early stage type 2 diabetes (just past "pre-" but not significant enough to warrant meds);
  2. I have had asthma for about 28 years;
  3. Diagnostics indicated fatty liver at one point, although liver enzymes have been well within normal more recently;
  4. I've had nonischemic/idiopathic cardiomyopathy/heart failure for 12 years. Well controlled with meds.
  5. The doc suggested a sleep study - he suspects sleep apnea (but I haven't done that yet...)
I had my first consult with a bariatric surgeon - a large practice, highly recommended by both my primary doc (who's been my doc for over 20 years) and endocrinologist. This Doc's name is Guske - he's part of the Kane Center for Advanced Metabolic & Bariatric Surgery in the Chicago area. I've not seen any of their names on the lists of "vetted" surgeons, which strikes me as odd because they are such a big center.

Everything I've read about DS (compared to other procedures - RYGB, sleeve gastrectomy) - tells me that DS is, by far, the best for long term success for co-morbidities.

My insurance DOES cover bariatric surgery - but NOT the DS procedure. At least that's what I remember reading on the insurance website reviewing covered procedures.

The surgeon said it was highly unlikely that the insurance would approve DS as an exception (on an appeal) given that my BMI is "only" 40 (he approval is typically only granted for BMI >50) and I'm also not on insulin (yet), so their argument will be that I'm not "co-morbid" enough to justify DS.

He suggested I do the sleeve gastrectomy since it is phase 1 of the DS. That it will help me lose enough weight to get the diabetes under control. And THEN seek the waiver to get "phase 2". While that makes sense (assuming the waiver for DS wouldn't be approved for all of the reasons), I've also heard that this is the approach of many surgeons when it comes to DS - that they take a 2 phased approach. (I've also heard all of the negatives and suspicion....that they want more money from two procedures; that they bait and switch...lure patients in with saying they do all the procedures, and then switch to a simpler procedure with a higher profit margin) My gut instinct is that's NOT what's happening with this guy.

He says he has done hundreds, and while it's a smaller part of the WLS he does because insurance doesn't often approve it, he does a few DS's a month. He said he would support my choice if that's the route I wanted to go.

I read on one of the DS sites that it's better to get approved for a procedure your insurance DOES cover (i.e., sleeve) and THEN move forward with appealing to get the other approved. So I'm researching that.

I'm basically left feeling at odds and also, if I'm being honest, a little disappointed - because I thought I'd be able to say "this is what I think is best for my body" and we'd be on our way. Complicating things is the fact that I'd totally go with this surgeon for a sleeve (he's local) - but would want to research other surgeons with more DS activity in their practices (which would mean traveling) if either a 2-phased approach or "virgin" DS.

So - that was a bit of a long intro. Now that I'm a member, I am going to read up on all the helpful info I've seen on here. Thank you for holding space for these conversations.
 

galaxygrrl

Well-Known Member
Welcome. I would fight like heck and get the DS. Larra and DianaCox to help with your insurance and appeal. The are awesome!

I got my DS done in MX for 11K and I could not be happier with it. My POV was that 11K was easier than the insurance BS I had to deal with and my insurence was still not going to cover anything. But, let Larra and Diana help you.

Good luck!
 

Munchkin

Full of Fairy Dust
I doubt he is a DS surgeon. Never heard of him. I would bet money he is priming you for a look alike procedure or something else. Probably SADI/SIPS/LOOP. Don't fall for it! Hold out for the real DS and appeal.

As far as the sleeve goes, do diets work for you? Guessing the answer is no or you would be thin. Right? The sleeve is restriction only. It's just a diet with a smaller stomach. And no your insurance is not going to pay for the rest of the DS down the road. Don't settle. Think twice. Cut once!
 

DianaCox

Bad Cop
I’m pretty sure he’s lying to you.

Larra and I help people win appeals for the DS almost every time. The DS is a standard of care procedure and is an option for essentially anyone who meets the criteria for bariatric surgery unless there is a specific contraindication.
 

southernlady

Administrator
Staff member
Welcome Annemarie I see you found us. Any, first thing to do is get a pdf or hard copy of your policy and then get with DianaCox and Larra to get things going.

I have a question tho, not of you but just wondering. How in the hell is someone NOT diabetic enough? I don’t care if you handle it with diet/exercise or oral meds or insulin, it’s still diabetes!
 

Annemarie

Member
I’m pretty sure he’s lying to you.

Larra and I help people win appeals for the DS almost every time. The DS is a standard of care procedure and is an option for essentially anyone who meets the criteria for bariatric surgery unless there is a specific contraindication.
Hi Diana - I'm Jillian's friend! (to give a "framework", maybe....I think she reached out to you last week?)

He's actually not lying. I confirmed that today. I spoke with his office, and then with BC/BS IL. I have downloaded the medical policy for Bariatric Surgery, based on your guidance in the thread you started that outlined the steps. I can't find it now (rats) - but one of the first steps was to get not just the Summary of Benefits Coverage but the actual policy. (thank you for that advice! if you see this and know where that thread is, can you respond with a direct link to it?)

The following procedures are considered not medically necessary as a treatment of morbid obesity:
Biliopancreatic bypass with duodenal switch as a treatment for patients with a BMI less than 50kg/m2
BC/BS advised that we'd first need to seek pre-authorization and then when it gets rejected, follow the appeals process. I swear I read somewhere (??? again - goddess knows where, I've read so much) - that it's better to get approved for, say, the VSG, and then appeal to SWITCH to a different procedure. Any thoughts on that?

What I found in the medical policy for bariatric surgery aligns with what Guske explained to me during the consult, and what his office explained to me today - that my insurance doesn't allow DS for BMI<50. And when I asked about my co-morbidities, that's when he talked about the severity of diabetes (mine being very early and mild and not at the level where meds would help....because i'm above normal, and above pre-D, but still below the target range they'd aim for with meds...) - southernlady, I don't think he was saying "not diabetic enough", just that as a comorbidity, because I am under 50 BMI, it wouldn't sway them. He said he'd support me getting whatever procedure I wanted, but was sharing what he had seen from insurance regarding approval.

I actually got a call from a sleep center to have a sleep study to confirm apnea. Which seems reasonable and would be needed regardless, so I might go ahead and do it.

But - for DS - we would have to appeal it to get it approved. Jillian warned me (she knows me so well), that I'd soon be diving head long into research and fact finding. I spent HOURS yesterday.

Based on what I found about procedures (comparing DS, RNY, VSG), it seems like DS is, by far, the best option for my co-morbidities. I can't figure out how to do a table on here. BUT - here are the numbers of % improvement in comorbidity:

Diabetes
DS: 92% (or 96%-98% depending on source)
RNY: 83%
VSG: 55% (or 70%, depending on source)​
Asthma
DS: 90%
RNY: 80%
VSG: 90%​
Fatty Liver
DS: 99%
RNY: 90%
VSG: N/A​
Sleep Apnea
DS: 99%
RNY: 98%
VSG: 62%​
Quality of Life
DS: 95%
RNY: 85%
VSG: 93%​

I am also a long-term congestive heart failure patient (virus attacked my heart in 2006) - managing very well (EF in the low normal range - cardio doc says I'm in remission!) with the tiniest dosage of the heart failure cocktail. But I couldn't find similar numbers for % improvement of CHF....

All of this said - and understanding that an appeal will likely be needed - I also confirmed with his office today that he DOES regularly do traditional/actual DS (and not SADI or whatever those other acronyms are that I'm still learning but not yet retaining in my acronym-addled brain), and that the lead doc in the practice (after whom the center is named) - Dr. Kane - does many more. She suggested I go to his seminar tomorrow night, at 6 pm, because there will be a DS patient there as well as more discussion about DS. So - I will do that just to get more info. I might ask Jillian if she can meet me there.

Even still, I am not certain that this practice is the one for me. They ARE recognized as a COE by BC/BS IL - but how odd that no-one hear has heard of them? How is that possible? hilary1617, thanks for the recommendation regarding Chicago docs. I am trying to make peace that I might have to travel for the surgery - and right now that stresses me out more than the idea of this surgery. It's interesting to me that there aren't more DS surgeons in a big metro area like Chicago. (have read also about Inman in Indy and Kemmeter in Grand Rapids....)

I think maybe I will use this thread here as a place to store all the info I gather - a) so it's easy for me to find online and b) maybe it will help someone else some day sorting through this stuff.

Thank your for holding this space. I'm grateful.
 

Larra

Well-Known Member
What your potential surgeon is telling you about insurance coverage doesn't make sense. If you are not unhealthy enough now for a DS (and I completely disagree with that, but not the point) get a sleeve and get lighter and healthier, you are even less likely to be approved for a DS down the road. That type or approach only works if/when someone is so unhealthy that the full DS would be too dangerous to do in one operation, the patient gets approval for the DS and gets it done in 2 stages to avoid dying on the OR table or shortly thereafter. That isn't you.

Get your EOC (evidence of coverage, a lengthy document that gives all the details of what is covered and what isn't). Let's see whether or not the DS is covered at all, and if so, with what criteria. If the only issue is a bmi below 50, that can often be overcome. If they don't cover it at all, doing a sleeve now won't get you covered in the future. Also, some policies have a "one bariatric surgery per lifetime" policy, in which case having a sleeve now will guarantee you won't get coverage for the DS in the future.

You are your own best advocate. Do not trust the surgeon, his insurance person, or anyone else to sort this out for you. And be open to the option of travel to get what you want. This is something you will live with for the rest of your life. The inconvenience of travel is temporary.
 

Annemarie

Member
Get your EOC (evidence of coverage, a lengthy document that gives all the details of what is covered and what isn't). Let's see whether or not the DS is covered at all, and if so, with what criteria. If the only issue is a bmi below 50, that can often be overcome. If they don't cover it at all, doing a sleeve now won't get you covered in the future. Also, some policies have a "one bariatric surgery per lifetime" policy, in which case having a sleeve now will guarantee you won't get coverage for the DS in the future.
I did get the EOC - Bariatric Medical Policy from BC/BS IL site (my post was so long it likely got lost).

Based on that policy, I "qualify" for bariatric surgery:
I meet the criteria for severe obesity - 40.2; I also have several co-morbidities in case I miraculously shed a few lbs (diabetes 2, asthma, apnea, heart disease). The issue is that DS is "not medically necessary" for BMI<50. So - I'll need to appeal it. But first need to either get approved for a different procedure and then appeal to switch, or else try to get DS approved from the outset and then appeal the rejection that will come based on my not-high-enough BMI of 40.2.
 

Larra

Well-Known Member
I'd be interested in what DianaCox thinks, but I would go with requesting the DS, getting the inevitable denial, and doing appeals. Your appeals rights are also somewhere in the EOC, and hopefully you have the option of external appeal, which is where you are most likely to succeed. If none of that works, you still have the option of requesting authorization for the sleeve after getting a final denial.
Your other option, of course, is self-pay. I don't know whether or not that's an option for you financially, but if it is, your best bet would be Mexico with Dr. Esquerra. Lots of people who could have had gastric bypass or sleeve paid for by insurance have self-paid for the DS instead. It's a shame that it sometimes comes to that, but I have yet to encounter anyone who regretted that decision.
 

Annemarie

Member
I'd be interested in what DianaCox thinks, but I would go with requesting the DS, getting the inevitable denial, and doing appeals. Your appeals rights are also somewhere in the EOC, and hopefully you have the option of external appeal, which is where you are most likely to succeed. If none of that works, you still have the option of requesting authorization for the sleeve after getting a final denial.
Your other option, of course, is self-pay. I don't know whether or not that's an option for you financially, but if it is, your best bet would be Mexico with Dr. Esquerra. Lots of people who could have had gastric bypass or sleeve paid for by insurance have self-paid for the DS instead. It's a shame that it sometimes comes to that, but I have yet to encounter anyone who regretted that decision.
Thank you. If insurance will pay for the VSG part of the DS....can I just self-pay for the DS part of the operation? Do they do that at all?
 

Larra

Well-Known Member
I don't know. You could always ask the surgeon if he/she is willing to go along with this idea. Perhaps someone with more legal knowledge can address whether or not this is a legit approach.
 

Annemarie

Member
Here is the link I found outlining the steps to take if you are denied for insurance (so I can find it again - and in case anyone else is interested):
Edited by admin
 
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