Hello. New here but not to WLS.

[Elinor Dashwood]

Hello, all. I am just lurking. Long story:

I had a VSG in 2009 and lost 70 pounds during the first four months. That was it. I never got to goal (another 30 pounds). I've had steady regain since then. I've been working on it. (My son is getting married in three weeks so that helps!)

I had GERD before the VSG, and I've had GERD since the VSG. ( I would not have had the VSG if info available today was available then. I would have had RnY. I was self-pay and could not afford DS.)

The GERD is not responding well to any medications any longer. I've had many tests (EGDs, barium swallows, some kind of thing where they made me eat eggs with something in them and then did nuclear imaging, a NASTY Bravo study). They all show severe GERD, erosion in my esophagus, and a large hiatal hernia.

My surgeon wanted to revise me to RnY to repair the hiatal hernia and elimnate the GERD (which at this point I am willing to do). I watched my grandmother die from esophageal cancer. I want to avoid that same outcome! But it's a $40,000 surgery. I cannot afford that. Our insurance has a specific exclusion for any kind of WLS, even if it is medically necessary. (Unless I might die within one year from not having the procedure , of course. Then they only MAY consider it.)

This site came up in my googling a cpt code I have been approved for: 43631 (Gastrectomy partial distal; with gastroduodenostomy) but my surgeon says that won't fix it long term. (And I'm not even sure what that is exactly. A Scoparino? A Bilroth?) So they've opened a new case under the cpt code 43633 (Gastrectomy, partial, distal; with Roux-en-Y reconstruction). But I've also seen things that just call 43633 "DS related". So I came here to see if anyone has any experience with that particular cpt code. Or knows what the procedure is called out here on the Interwebs. The surgeon says he thinks this will be approved. I am not as optimistic as he is. But we will appeal and appeal and request an Independent Review if they do not.

Sigh. This has been going on for 18 months now. I just want the reflux GONE. (And even a 70-pound weight loss did not help with that.) My current BMI is 35. My lowest was 28.

I'd appreciate any information regarding the cpt code 43633. Thank you!

 

[newanatomy]

Hello and welcome. I hope you get the answers and help you need.

 

[southernlady]

Welcome @Elinor Dashwood

Gonna tag @Larra and @DianaCox, they may know what you need as far as the CPT code.

 

[Larra]

Diana will probably know the right code. What I can say is that "partial distal gastrectomy" sounds like the old BPD, not a DS. With a DS you get a sleeve gastrectomy, which you already have, combined with the "switch" part where the duodenum is divided just past the pyloric valve and roughly half of the small intestine is bypassed. With a distal gastrectomy you LOSE your pyloric valve - gone forever, and the small intestine is attached to the proximal stomach, or in your case to whatever is left of your pre-existing sleeve after the distal part of the sleeve is removed.
I can't think of a how this is supposed to help with your reflux and esophageal problems, except if whatever is in your remaining sleeve falls out into the small intestine, which sets you up for dumping and/or reactive hypoglycemia. Perhaps the surgeon you have seen has some other explanation.
The main reason the modern day DS was created was to avoid the problems caused by the old BPD, these being diarrhea and nutritional deficiencies. It worked well for weight loss, but those complications can be significant, and there is no going back in the sense that once the distal stomach with its pyloric valve is removed, you can't undo that.
I hardly ever recommend gastric bypass for anyone, but it is known to be beneficial for severe reflux. That's really the only comorbidity where it's superior to the DS. My only other thought, though, is that if you have a significant hiatal hernia that may be part of your reflux problem, and its something that can be corrected along with whatever bariatric operation you have.
If you haven't already, I would recommend that you at least have a consultation with a surgeon who does the DS on a regular basis and see what he/she thinks would be most helpful for you. And personally, I would avoid a distal gastrectomy like the plague.

 

[Elinor Dashwood]

Thank you, @Larra. I haven't spoken directly with the surgeon yet regarding this cpt code, just his office person who has been EXTREMELY helpful (and is also the one who told me he thought it would be approved). She's called and called the insurance company to talk to them about my case. (If I can ever get this fixed, I am taking her champagne and roses!)

My surgeon is Dr. Steven Simper. He's a great surgeon. I trust him. (He also saved my life when he did my VSG. I had been feeling ill for over a year and had numerous tests, all negative. I finally marked it down to just being so darned overweight. He suggested I have a HIDA scan to check my gall bladder. (No stones had been found on two ultrasounds.) The HIDA scan showed a very sick gall bladder. When he took it out the next day, it fell apart because it was gangrenous. He said he'd done over 2,000 gall bladder removals and had never had that happen. He told me I would have gone into sepsis and needed exploratory surgery if it had gone on just a couple of weeks longer.)

I was hoping that cpt code didn't mean distal bypass as I've been seeing negative things about that procedure. Big sigh. If it gets approved, then I will definitely be speaking with him about the details. It's just too much time to do it before I know it is approved.

 

[Larra]

Dr. Simper does do the DS and has a good reputation. So I think the big issues are the right code and how to pay for the right operation. I'm sure someone will come along who knows the right code, and I hope the office staff can help with your insurance. I would recommend that you request a copy of your EOC (evidence of coverage) if you don't already have it. This is a lengthy document that gives the specifics of what is and isn't covered and also what appeal rights you have, if any. It's clear you have already done some research both about your insurance and about the different operations, so you are already on the right path, but you need to know the details of your coverage. It really is shameful that even medically necessary care isn't always covered. Maybe Dr. Simper can present your case as not being necessary in terms of weight loss, but rather as treatment of the problem of reflux and Barretts, which many people who are not overweight and have never had any kind of bariatric surgery also experience. And wouldn't they at least cover repair of a hiatal hernia? This is an issue that your EOC should address.

 

[Elinor Dashwood]

Because the codes they have already tried are "weight loss surgery" cpt codes, my insurance denies the procedure. Even though it has been stated over and over that it is for treatment of GERD/hiatal hernia and not for weight loss. Christina (the woman I have been working closely with in Dr.Simper's office) said he will insist on a peer-to-peer if they deny this code. (Although they have stonewalled on a peer-to-peer on the other codes.)

I have been over the EOC. (Which, of course, I cannot find right now because I am buried in wedding stuff. I have no idea where I put it!) There is no wiggle room. My only choice is to go through the appeals process and then file a notice for a request for an Independent Review. If the IR is negative, then I have to file a complaint with my state insurance commission. I am really just wondering if THIS is the code to fight for or not.

Edited to add: They do cover fundoplication for treatment of hiatal hernia, but I cannot have one due to having had the VSG. So they say this is now a complication of an uncovered procedure. (That's not the exact language, but that's what it means.)

 

[brooklyngirl]

Welcome @Elinor Dashwood , I hope you get the info you're looking for. Lots of people here have fought the insurance companies and won

 

[marissamast]

Thank you, @Larra. I haven't spoken directly with the surgeon yet regarding this cpt code, just his office person who has been EXTREMELY helpful (and is also the one who told me he thought it would be approved). She's called and called the insurance company to talk to them about my case. (If I can ever get this fixed, I am taking her champagne and roses!)

My surgeon is Dr. Steven Simper. He's a great surgeon. I trust him. (He also saved my life when he did my VSG. I had been feeling ill for over a year and had numerous tests, all negative. I finally marked it down to just being so darned overweight. He suggested I have a HIDA scan to check my gall bladder. (No stones had been found on two ultrasounds.) The HIDA scan showed a very sick gall bladder. When he took it out the next day, it fell apart because it was gangrenous. He said he'd done over 2,000 gall bladder removals and had never had that happen. He told me I would have gone into sepsis and needed exploratory surgery if it had gone on just a couple of weeks longer.)

I was hoping that cpt code didn't mean distal bypass as I've been seeing negative things about that procedure. Big sigh. If it gets approved, then I will definitely be speaking with him about the details. It's just too much time to do it before I know it is approved.

MY surgeon was also Steven Simper and I have never dealt with such a bungling bunch of inefficient half assed nincompoops in my life! What a joke that office is. You have my sympathy that your health is in their hands. I went back for my surgical follow up and never went back. Best of luck.

 

[star0210]

Seems I've read about several people who had severe GERD caused by a hiatal hernia. Can they not fix that first to see if that resolves or mostly resolves the issue?
I hate to see anyone lose a perfectly good half of a DS for the RNY. That makes me sad.

 

[Elinor Dashwood]

Wow, @marissamast! We have had opposite experiences. I have had only help from Dr. S's office staff. I am sorry your experience was not that way.

@star0210 I cannot have a fundoplication (which is how a hiatal hernia is usually treated) because of my VSG. My sleeve is not big enough/there is no excess stomach? The gastro was not clear why he couldn't do a straight-up repair. He just said he couldn't fix it and referred me to my surgeon.

 

[Larra]

@Elinor Dashwood it sounds like @marissamast 's bad experience is more with the office staff than with Dr. Simper (though of course I could have misunderstood her, and I apologize if so). To me, this says that it's all the more important that you get the right code for the operation you want before anyone submits anything for approval.

And while it's true that a fundoplication isn't possible with your sleeve, would it not be possible for the surgeon to repair the hiatal hernia by making the opening in your diaphragm more narrow so that your stomach and the lowest part of your esophagus stay below the diaphragm where they belong? Not ideal, but better than nothing.

 

[Elinor Dashwood]

@Larra I asked the gastroenterologist if there were other ways to fix it besides fundoplication, and he said RnY was the best choice for my situation. So I went to see Dr. Simper and have been fighting this insurance fight ever since. I suppose what I really need to do is to make an appointment and go have a sit-down with Dr. S, and see what he says about how to fix it. I do know Christina has been working closely with him on which cpt code to submit.

 

[southernlady]

@Larra I asked the gastroenterologist if there were other ways to fix it besides fundoplication, and he said RnY was the best choice for my situation. So I went to see Dr. Simper and have been fighting this insurance fight ever since. I suppose what I really need to do is to make an appointment and go have a sit-down with Dr. S, and see what he says about how to fix it. I do know Christina has been working closely with him on which cpt code to submit.

The gastro may not know of the DS or the best way...Dr. Simper is a good one to ask.

 

[Larra]

I agree with a personal discussion with Dr. Simper, and also hope someone will chime in with the correct code. @DianaCox ??