Hoping for some advice from the experts!

[FloridaJen]

Ya'll don't know me (well 1 or 2 of you might from the OLD OLD days of Spotlight Health [hi Sue!], but I joined here in 2015 when I was strongly considering WLS #2. And Thanks Larra for redirecting me here from OH!

I self-paid for the Lapband (or crapband as it seems to be referred to around these parts) in 2002 (in Monterrey) and had it removed in 2009 through insurance (in Florida.) At that time the surgeon who removed my band was desperate to do the RnY at the same time and I was (and still am) completely opposed to that procedure. I was around 270 lbs then and he told me I'd come crawling back when I was well over 300 lbs. I was SO insulted at the implication I could not do this myself. Ha, what a child I was. Here I am 10 years later at a 52 BMI, injecting myself with insulin 3 times a day and using a machine to sleep. Not to mention hypertension, high cholesterol and joint pain so bad I can hardly live my life.

I came here when I was first diagnosed with Type 2 because I was terrified of what my future, or lack thereof, was going to look like. Turns out I was more scared of surgery. I know that the Sleeve is not enough and the SIPS, while appealing, was (and apparently still is) experimental. The DS just seemed TOO drastic. But now, now it's a different ballgame. I'm 44 and I'm ready to do this. Still scared, but ready.

But now the battle to find a surgeon begins. I'm in Florida and I've been all over the map trying to find a surgeon who is experienced and qualified to do DS. At first, I wanted one that also did SIPS, so I could really make an informed decision, but I'm feeling less and less like that's a smart option. SO I am trying to get into Dr. Smith's place, but the staff seems to be having a challenge verifying my insurance. I 100% know that I have coverage with a high copay but she called me and said I have no coverage for bariatric surgery. Why must everything be so difficult?

I was referred to Dr. Jawad and also looking at Dr. Wizman. I see all the shady stuff with Jawad and nothing about Wizman. Should I rule both of these surgeons out and only fight for Dr. Smith?

OR if I travel - how do you handle pre-ops and most importantly follow-ups? One of the struggles I had with the band was I didn't have any proper follow-up and I'm really afraid of being on my own after a surgery like the DS, especially without a good quality bariatric surgeon nearby. I don't think I will be able to find a PCP who is going to be on board with handling my labs, much less be educated enough to decipher them. And good PCPs are difficult to come by around here.

Would love any advice you have to offer. Once I find my surgeon I will come back with my 100 other questions about vitamins post-op. lol

Came back to edit for one more thing...
I went to a surgical consult last week with my mom to have her hiatal hernia repaired. She saw a very well known bariatric surgeon - Dr. Rosenthaul - and while there I asked him about the DS. Whoa boy did he have strong opinions against the DS. He said there is a reason it's rarely done, even after all these years, and I might not regret it right away, but 10-20 years down the road I will. How did you all overcome the fear with well-respected surgeons trying to scare you into the Sleeve, or even worse - the RnY?

Thanks gang!
Jen

 

[southernlady]

Welcome Bring it Jen.
Fight for Smith in Celebration. The other ones close to FL is Dr. Jean-Pierre, who mentored with Smith and inherited his office in Marietta, GA, Dr. Boyce in Knoxville who mentored under Dr. Smith about 10 years ago, Dr. Sudan at Duke in NC. Those are your closest ones.

 

[FloridaJen]

Thank you. That’s what my gut is telling me. Pun intended. I just hope they can get it together to verify insurance.

Welcome Bring it Jen.
Fight for Smith in Celebration. The other ones close to FL is Dr. Jean-Pierre, who mentored with Smith and inherited his office in Marietta, GA, Dr. Boyce in Knoxville who mentored under Dr. Smith about 10 years ago, Dr. Sudan at Duke in NC. Those are your closest ones.

 

[Larra]

Hi there!
It would be helpful to review your EOC (evidence of coverage, a huge document that provides all the details of your coverage, not a summary of benefits) to help figure out what the hold up may be. Many policies have different coverage for revision bariatric surgery than for a primary operation, some don't cover it at all. ask your HR (or spouse's if appropriate) and be prepared to be met with ignorance and need to speak with supervisors.
Dr. Smith has an excellent reputation. Dr. Jawad - no. Never heard of the other guy before. Many medical professionals, including surgeons who are not bariatric surgeons, are amazingly ignorant about the DS. Yes, we've seen people with nutritional deficiencies over the years, but most of the time it's because they slacked off on their supplements. The protein and supplements are a life time commitment to yourself and your health, but some folks decide they are special and don't need them like the rest of us. Big mistake, but deficiencies can be tough to treat and a doc who has struggled to save one person with malnutrition doesn't forget that case. Makes the DS look bad, when really, it isn't. Do your own research, as you are doing, and make the choice that's best for you.

 

[FloridaJen]

Hi there!
It would be helpful to review your EOC (evidence of coverage, a huge document that provides all the details of your coverage, not a summary of benefits) to help figure out what the hold up may be. Many policies have different coverage for revision bariatric surgery than for a primary operation, some don't cover it at all. ask your HR (or spouse's if appropriate) and be prepared to be met with ignorance and need to speak with supervisors.
Dr. Smith has an excellent reputation. Dr. Jawad - no. Never heard of the other guy before. Many medical professionals, including surgeons who are not bariatric surgeons, are amazingly ignorant about the DS. Yes, we've seen people with nutritional deficiencies over the years, but most of the time it's because they slacked off on their supplements. The protein and supplements are a life time commitment to yourself and your health, but some folks decide they are special and don't need them like the rest of us. Big mistake, but deficiencies can be tough to treat and a doc who has struggled to save one person with malnutrition doesn't forget that case. Makes the DS look bad, when really, it isn't. Do your own research, as you are doing, and make the choice that's best for you.

You bring up a good point about revisions. I honestly don’t think of it as revision because 1. I self paid for my stupid band 17 years ago 2. Had it removed 10 years ago under different insurance, due to slippage/reflux (if I remember correctly)

I’ve had two places verify insurance, 1st one said I have the once per lifetime bullshit and requested reports from the surgeon who removed my band. I asked why having a band removed 10 years ago even has to be brought into this. I don’t really understand how that works. I haven’t heard back from them and wasn’t going to bother now because they don’t do DS.
2nd place verified with no problem and told me what my responsibility was to be and it was as I understood it. $6k copay. But they also don’t do DS.

Smiths office said very specifically it didn’t cover any Bariatric Surgery at all. She said they just gave the surgery codes, don’t think I’ve told them about my band.

Am I screwed?

 

[Larra]

This is exactly why you need the EOC. Once you have it, if you still aren't sure about your coverage, there are folks here (mostly DianaCox and me, but others also) who can translate it for you.
If you have a "one per lifetime" clause, you might be screwed, but even then you can argue that the band had to be removed due to a complication (slippage). Hopefully you have or can get documentation of the complication. Whether or not that will make a difference, IDK. Past experience for others is that having paid for prior bariatric surgery yourself or with a different insurer still counts against you.
So get your EOC and we'll go from there.

 

[FloridaJen]

This is exactly why you need the EOC. Once you have it, if you still aren't sure about your coverage, there are folks here (mostly DianaCox and me, but others also) who can translate it for you.
If you have a "one per lifetime" clause, you might be screwed, but even then you can argue that the band had to be removed due to a complication (slippage). Hopefully you have or can get documentation of the complication. Whether or not that will make a difference, IDK. Past experience for others is that having paid for prior bariatric surgery yourself or with a different insurer still counts against you.
So get your EOC and we'll go from there.

I’m going to cry. This is unbelievable.

 

[DianaCox]

The once in a lifetime exclusion applies to you. But there are arguments against it. The ASMBS position statement on revision bariatric surgery denounces it. The ACA says no pre-existing condition exclusions. You didn’t fail the crapband, it failed you and besides, is now known to be essentially useless. These arguments may or may not work, but there’s a decent chance they will.

And you can get different insurance in January or when you change jobs.

 

[harrietvane]

Depending on how high your co-pay is, any chance you can afford to self-pay at somewhere like Mexicali?

I travelled from Singapore to Canada for mine, alone. I had no issues pre- or post-op. The clinic organised care for the first few days post-surgery, and then I hung out for a few more days until I was able to travel more comfortably. The most you will probably need if you did decide to travel is some help with your bags and possibly some mobility assistance in the airport.

 

[Settledownnow]

The protein and supplements are a life time commitment to yourself and your health, but some folks decide they are special and don't need them like the rest of us.

This is the bottom line on noncompliance on supplements.

 

[Larra]

Don't give up. Get that EOC and let's figure out where you stand.

 

[FloridaJen]

The once in a lifetime exclusion applies to you. But there are arguments against it. The ASMBS position statement on revision bariatric surgery denounces it. The ACA says no pre-existing condition exclusions. You didn’t fail the crapband, it failed you and besides, is now known to be essentially useless. These arguments may or may not work, but there’s a decent chance they will.

And you can get different insurance in January or when you change jobs.

Changing jobs is not an option and I don’t see how I can change insurance? And yeah, my band slipped and I was throwing up 3 times a day. With 3 different places verifying insurance this has only come up once. When does it come up that I had a band before?

 

[FloridaJen]

Don't give up. Get that EOC and let's figure out where you stand.

Ok. I do feel defeated, insurance has always always failed me. I’m just so exhausted I don’t know how I’m going to fight this.

 

[FloridaJen]

Depending on how high your co-pay is, any chance you can afford to self-pay at somewhere like Mexicali?

I travelled from Singapore to Canada for mine, alone. I had no issues pre- or post-op. The clinic organised care for the first few days post-surgery, and then I hung out for a few more days until I was able to travel more comfortably. The most you will probably need if you did decide to travel is some help with your bags and possibly some mobility assistance in the airport.

I can’t do that again, just can’t. Financially or emotionally. It was a mistake for the band and while I know the care is good I need the protection of this country and local doctors if I’m going to have this surgery.

 

[FloridaJen]

This is exactly why you need the EOC. Once you have it, if you still aren't sure about your coverage, there are folks here (mostly DianaCox and me, but others also) who can translate it for you.
If you have a "one per lifetime" clause, you might be screwed, but even then you can argue that the band had to be removed due to a complication (slippage). Hopefully you have or can get documentation of the complication. Whether or not that will make a difference, IDK. Past experience for others is that having paid for prior bariatric surgery yourself or with a different insurer still counts against you.
So get your EOC and we'll go from there.

Couldn't find anything online that said EOC, but did find "benefits booklet" so I've ordered that - which will take 10 days.