Need help reading EOC & more HMO Questions

[HereIGoAgain]

Hi there. I am learning more and more about my current issues and really do not want to revise to RNY but I cant seem to find in my EOC what exactly are my options. In fact from what I can tell it doesnt mention a word about Bariatric Surgery (though I know there is coverage from my statement of facts, it just doesnt give any clarifying info in that doc).

Just to review, I had sleeve surgery almost 4 years ago. I have had constant horrible heartburn since having it done and have not been very successful with weight loss. I currently have three hernias. One is a ventral hernia that is causing horrible pain. Another is a umbilical fat filled hernia (which as far as I can tell isnt causing any issues) and the other is a hiatial hernia, also causing quite a few issues. I met with a general surgeon who says he will only be able to repair the ventral and umbilical hernias. I have an appointment next week with the gastroenterologist to figure out what to do with the hiatial hernia and to discover if my pyloric valve is not functioning right.

In addition to needing help reading my explanation of coverage, I am wondering how most of you with HMO insurance went about seeing a DS surgeon? Given that they are relatively spread out I cant imagine they are easy to get a direct referral to. I am hoping to see Dr Keshesian in California but my BMI is only 37 so I dont even know if they would consider me. I could really use some advice. What is someone with a lower BMI supposed to do if revising is necessary due to complications like hernias and pyloric valve issues? Are we supposed to just go with RNY or ignore the issues? I am attaching my EOC just in case someone is better at reading through this that I am.

Thanks in advance!

 

[Marquis Mark]

I have Kaiser SoCal. They have one surgeon, Dr. Belzberg, at Kaiser Harbor City (30 minutes south of LA) who does the DS. He converted me from a sleeve to DS at a 37 BMI. As long as you can convince him you've studied the DS he'll be OK. Of course, you'd have to switch to Kaiser and then call Harbor City Bariatrics and tell them you want an appt with him. If they give you a hard time tell them you switched to Kaiser just to speak with him! He's a highly skilled GI surgeon so I imagine he might be able to deal with your pyloric valve/hernia issues as well.

Good luck.

 

[HereIGoAgain]

I have Kaiser SoCal. They have one surgeon, Dr. Belzberg, at Kaiser Harbor City (30 minutes south of LA) who does the DS. He converted me from a sleeve to DS at a 37 BMI. As long as you can convince him you've studied the DS he'll be OK. Of course, you'd have to switch to Kaiser and then call Harbor City Bariatrics and tell them you want an appt with him. If they give you a hard time tell them you switched to Kaiser just to speak with him! He's a highly skilled GI surgeon so I imagine he might be able to deal with your pyloric valve/hernia issues as well.

Good luck.

Thank You Mark! I wont have open enrollment again until July of 2017 but you know sometimes these things take a very long time so if I am unable to move forward until then I am definitely open to switching.

Thanks again!

 

[DianaCox]

You go to your PCP, and ask for an out of network referral to DrK, because you are having complications including multiple hernias and failure of the sleeve alone to attain or maintain sufficient weight loss, for which your research indicates the DS would be the best of the standard of care bariatric revision procedures to address your issues without the drastic and unacceptable step of destroying your perfectly good sleeve and losing your pyloric valve function with an RNY. Tell your PCP you have reviewed the list of in-network bariatric surgeons and general surgeons, and none can provide the DS at all, and in fact none can even repair your hiatal hernia due to having a sleeve (can't do a proper Nissen fundoplication - requires a specialized procedure), much less in the same procedure with the repair of incisional and umbilical hernias. Having done your research, the most skilled and competent surgeon, who is in-network with Blue Shield, though not with your specific HMO, is DrK. Therefore, you want an out of network referral to see him.

The PCP might surprise you and agree to the referral. If not, you will have a denial on the record (make sure you get it in writing and not just the PCP saying no), and you can go ahead and self-pay for a consult with DrK, which will garner you a letter of medical necessity to use in your appeal. Your appeal rights - including to recoup the cost of the self-pay consult - will be vested by receiving the formal denial first.

 

[HereIGoAgain]

Thank You so much Diana. I am going to try to get information about my precise coverages for DS prior to my upcoming appointment with my PCP. Quick question I am wondering if you know the answer to. Do you think it is within the scope of practice for a bariatric surgeon, like Dr K, to fix the other two hernias at the same time? I would really like to get everything fixed at once but the general surgeon made it sound like they dont generally get addressed together given that they are in different areas. With the intense pain I am getting from the ventral hernia Id like to get it fixed as soon as possible but if its likely Dr K can fix both Id really want to push harder to get a consult to see him very soon. Thanks again!

 

[DianaCox]

I'll let Scott answer your questions in detail, but in fact DrK just did his abdominal hernia repair a few weeks ago.

 

[HereIGoAgain]

Thanks again!

 

[galaxygrrl]

Here is some info for you - http://www.bariatric-surgery-source...-surgery.html#minimum_requirements_California

The other thing since you are in SoCal is you can think about self pay in Mexicali with Dr. Esquerra who is a very experienced and talented surgeon. When I had my virgin DS, there was a woman there who had a revision and a hiatial hernia fixed. I know it's not ideal, but if you need to self pay, it's an option. I know Mexico sounds crazy, but it's actually not with this Dr. I think with others it might be. I choose Mexico in part because I just wanted to get the surgery done.


This site was correct for Aetna for me.

 

[DSRIGGS]

Helol @HereIGoAgain

Apologize because in the other thread I thought you already had your DS revision.

First, please don't even consider the RnY for exactly why Diana stated.

Second, Dr K can absolutely do hernia repair at the same time. When he revised me because of malnutrition issues he fixed a small ventral hernia, an internal hernia another surgeon repaired a year earlier that had opened back up and he repaired an anal fissure.

Then this May my weak abdominal wall had to be repaired again and Dr K put in an 8 x 10 hunk of mesh to keep that bastard from coming back.

Best of luck. Feel free to PM me if you have other questions.

 

[Susan in Tennessee]

Helol @HereIGoAgain

Apologize because in the other thread I thought you already had your DS revision.

First, please don't even consider the RnY for exactly why Diana stated.

Second, Dr K can absolutely do hernia repair at the same time. When he revised me because of malnutrition issues he fixed a small ventral hernia, an internal hernia another surgeon repaired a year earlier that had opened back up and he repaired an anal fissure.

Then this May my weak abdominal wall had to be repaired again and Dr K put in an 8 x 10 hunk of mesh to keep that bastard from coming back.

Best of luck. Feel free to PM me if you have other questions.

I might be remembering her original post wrong, but wasn't she asking if hiatal hernia could be repaired same time as the other two (other way around, actually) with the DS? Again, I could be 'membering wrong.