VSG to DS with Dr.Keshishian - SoCal

[Platti]

Hi there,

I moved my thread over this way from here: https://bariatricfacts.org/threads/self-pay-through-dr-rabkin.7944/#post-105306

I am now going through my insurance - Blue Shield of California. I believe I will once again be proceeding as a self pay.

I managed to get a copy of my Evidence of Coverage but cannot make heads or tails of it. I cannot attach it here as its 138 pages long but you can view it by going here: Evidence of Coverage - Gold Full PPO 500/300 OffEx

I am not a Resident of a Designated County.

I've also found: Bariatric Surgery Medical Policy and Pre-Authorization Form

Can someone help me gather what I need?
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Matt from Dr.Rabkin's office sent over:
Here is the documentation Blue Shield requires, according to their published criteria:

- Documentation of your having failed to lose weight to the point of your body mass index being less than 35 at the time of surgery, via non-surgical measures (including medication and nutritional counseling) for 3 of the past 6 months before surgery, despite one of the following:

1. Your having participated in a documented (including your initial weight, end weight, and the start date and end date), structured, physician-supervised weight-loss program which includes an exercise program as tolerated or available; or
2. Serially-charted documentation (including your initial weight, end weight, start date, end date, and notes from two clinician-directed follow-up visits) of your having participated in another managed weight-loss program including dietary control and exercise as tolerated or available (this option includes commercial programs, dietician-supervised programs, and diabetes management programs).

- A sleep study report which shows that you have clinically significant obstructive sleep apnea (which Blue Shield defines as an apnea-hypopnea index [AHI] of at least 15 events per hour, or an AHI of at least 5 events per hour in a patient with excessive daytime sleepiness or hypertension).

- A few different checklist-type documents, which you and/or Dr. Rabkin would need to complete and sign (I can send these to you if/when needed). They also need the person who did your psychological evaluation to complete a checklist, and I can send that to the evaluator and have them get it back to me.

- Documentation of your weight loss history after your VSG.

- Documentation of your having complied with your VSG surgeon's diet and exercise recommendations.

- The operative report from your VSG.

- Blood Work (I can send you an order for the specific things they need).

- A chest X-Ray.

- An electrocardiogram.
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I had my VSG done through Kaiser years ago and they handled this portion for me so I am unfamiliar with it.

Any and all help is very much appreciated, thank you!

 

[Platti]

Larra I got a copy of my Evidence of Coverage from Blue Shield of CA . I linked it above

 

[Platti]

"That would play into my decision-making. In fact, it did.

I started at USC Hospital, because back then (15 yrs ago), there was an experienced DS surgeon there. Then I went to Keshishian, about a 3.5-4 hour drive. (He has since moved to the LA area.). I would have, at least, TRIED to justify the out of pocket cost at the (then) Rabkins‘, many hours away, but once I met Keshishian, it was a no brainer.

But...what are YOUR priorities? If Rabkin and Keshishian were located in the same place and handled billing the same way, It would be a tougher call, right? LOL Is rapid access more important? Will you HATE the long trip home? Do you need to NOT hit up your 401k to pay for this?"

Spiky Bugger This is exactly where I am running into an issue as a self-pay patient. I just got off the phone with Silva with Dr.Keshishian's office and have a consult scheduled with him.

The biggest difference between the two is cost. Dr. Rabkin is quoting $30-$35,000 self pay for a VSG to DS. Dr. Keshishian is quoting $15-$20,000.
I wouldn't hate the drive home as its only a couple of hours but Dr. Rabkin is literally 30 minutes away from home.
I will be putting this procedure on a credit card to pay for it over time vs pulling from my 401k to pay right away. the $10-15,000 difference is HUGE given Dr.Rabkin is double the price of Dr.Keshishian.

I had been leaning towards Dr.K as he has many people who praise him highly and great bedside manner is EXTREMELY important to me (my VSG was HORRIBLE, but thats a story for another time). I just didn't think Dr.K would be in my price range.

 

[Larra]

Well, maybe I missed it, but this EOC wasn't terribly helpful. The section about bariatric surgery (I think page 24 or thereabouts) really only discussed transportation issues. It did imply, at least, that bariatric surgery is covered, but that's not very helpful for someone looking for a revision (though of course much better than not covered at all, and there are lots of policies that completely exclude bariatric surgery even when medically necessary).
So, I looked under the "exclusions" section around page 94-96 or so, and there is nothing specific except that any care they will cover for any condition must be medically necessary. The big remaining questions are, what do they consider medically necessary for bariatric surgery, which I couldn't find though we have a good general idea, and do they cover revisions and if so, what criteria do they use for revisions.
Sorry I couldn't do better. Maybe the staff at Dr. K's office will be more helpful. And as far as which surgeon, I think they're both excellent, but that's a significant cost difference. A couple hours drive home vs. 30 minutes isn't a huge difference to my mind. Of course, someone else needs to do the driving no matter where you go. It's your call.

 

[Platti]

Thanks for looking through the document Larra I agree that it isn't very informative.

At half the price, a VSG to DS self-pay through Dr.K isn't too bad (I was prepared for up to $25,000 tbh) and I will finance this as though it was a car I was purchasing for myself

I have a consult with Dr.K next week and am a little nervous. Do you have any questions that you recommend asking?

 

[Larra]

Someone else who posts here (you know who you are!) sent me more info in an email on BC Bariatric Policy, which I will attempt to copy/paste here.



Revision Bariatric Surgery for Inadequate Weight Loss

Revision of a primary or a subsequent bariatric procedure that has failed due to inadequate weight loss may be considered medically necessary when all of the following are met:
• All initial primary bariatric surgery qualification criteria have been satisfied (see Initial Bariatric Procedure above)
• Two years have elapsed since prior bariatric surgery
• Inadequate weight loss resulted from initial procedure; less than 50% expected weight loss and/or weight remains greater than 40% over ideal body weight (normal body weight BMI parameter = 18.5-24.9)
• Ineffective weight loss attempts within the year prior to revision surgery, including but not limited to compliance with previous post operative nutrition plan and exercise program is documented



Requirements for Initial Primary Bariatric Surgery



Bariatric surgery for the treatment of morbid obesity may be considered medically necessary when all of the following criteria are met:
• The patient is an adolescent or older with morbid obesity, and all of the following:
o The patient and physician together have reviewed, completed and signed the Bariatric Surgery Decision Aid
o The patient has reviewed, completed and signed the “CollaboRATE” survey
o Documentation with either of the following:
 A body mass index (BMI) greater than 40 kg/m2
 A BMI greater than 35 kg/m2 with at least one clinically significant obesity-related disease, including but not limited to:
 Type 1 or 2 diabetes mellitus
 Clinically significant obstructive sleep apnea ; or obesity hypoventilation syndrome
 Coronary artery disease, with documentation of atherosclerotic heart disease as evidenced by any of the following:
 Stress study
 Coronary angiography
 History of heart failure
 History of myocardial infarction
 Prior coronary artery bypass
 Prior percutaneous coronary intervention (PCI)
 Hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic in spite of the concurrent use of at least 3 anti-hypertensive drugs, one of which may be a diuretic

Painful or activity-limiting osteoarthritis involving the lower extremities, with radiographic documentation of joint space narrowing, osteophytes, subluxation, or subchondral sclerosis

 Hyperlipidemia (LDL cholesterol of 160 mg/dL or higher), uncontrolled by diet and medical therapy

 Gastroesophageal reflux disease (GERD), based on ambulatory pH probe monitoring, or endoscopic findings of ulcer, strictures, Barrett’s esophagus, or esophagitis and failing maximal medical therapy (e.g., proton pump inhibitors, H2 blockers, and/or prokinetic agents titrated to maximal recommended dosages)

• The patient has failed weight loss to a BMI less than 35 kg/m2 at the time of surgery by conservative (including pharmacologic and nutrition counseling) measures for 3 of the past 6 months, despite one of the following:

o Documentation of participation in a structured physician-supervised weight-loss program including an exercise program as tolerated or available

o Serially-charted documentation, including notes from two clinician-directed follow-up visits, of participation in another managed weight-loss program including dietary control and exercise as tolerated or available (commercial, dietician, or diabetes management programs)

• The patient has been evaluated for, and has received, maximal therapy for any secondary (e.g., endocrine) causes of obesity, has been evaluated for and treated for any pulmonary, gastrointestinal (including GERD), neoplastic, and cardiac co-morbidities which may impact surgery, and has been medically cleared for surgery, as documented in the Pre-Operative Checklist



The patient has received a comprehensive psychosocial-behavioral evaluation signed

by a qualified mental health professional clearing the patient for surgery, as documented in the Psychosocial-Behavioral Checklist

The patient has undergone educational counseling or a formal class giving a comprehensive understanding of the available bariatric surgery procedures, of how the patient’s life will be changed after surgery, the morbidity and mortality associated with this surgery, and the commitment required to make the lifestyle changes necessary to

maintain the health improvements achieved through surgery

No tobacco smoking for at least 6 weeks prior to surgery

No ongoing drug abuse or treatment within the past year

The bariatric surgery is performed by properly credentialed surgeons, and preferably at Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited hospitals that follow the American Society for Metabolic and

Bariatric Surgery (ASMBS) guidelines, including a multidisplinary program experienced in obesity surgery that can provide all of the following:

o Nutritional counseling

o Exercise counseling

o Long-term monitoring including both of the following:

 Psychosocial counseling

 Support group meetings

She also pointed out that co-pays will be less with Dr. K IF he is in network, compared to Dr. R., and that if you go self-pay you should consider what would happen financially if there are any complications.

 

[Platti]

She also pointed out that co-pays will be less with Dr. K IF he is in network, compared to Dr. R., and that if you go self-pay you should consider what would happen financially if there are any complications.

Complications like during the actual surgery part or afterwards? I was under the impression that I would be able to use my existing insurance to cover treatments needed post-surgery (nutritionist, labs, psych/therapist, etc)

 

[Platti]

I know you are handling this yourself, but when I went from VSG to DS the surgeon's office handled everything... Is it possible to ask the surgeon for more help? They deal with insurance all the time, for you, it is once in a lifetime

In my case, the surgeries were one year apart, the same surgeon did both

Good luck

I'm following up with Dr.K's office on Monday to see what we can do and whether or not I can go through insurance or self-pay.

Both Dr.Rabkin and Dr.Keshishian are out of network for me and Dr.K's fees and breakdown are so much lower than Dr.Rabkin for the same level of expertise. Having talked with Dr.K sealed the deal for me - he's funny, personable, and very understanding. He made me feel very heard, answered all of my questions, and was very humble about his reputation telling me, "They're all paid advertisement, don't believe them" to which we both laughed.

The biggest dealbreaker for me between Dr.Rabkin and Dr.Keshishian - surgery method. Dr.Rabkin's office informed me that Dr.Rabkin does his revisions Open. When I asked Dr.K about whether my DS would be done open or laparoscopically, he told me, "Laparoscopically... I mean, I can open you up if you really want me to..." This is what made the scale tip in Dr.K's favor and has me proceeding with him. I do not want to have an open procedure done if it is not absolutely necessary, and it was the biggest source of anxiety for me.

I still cannot find any information about Dr.Rabkin and his personality, demeanor, or bedside manner and that concerns me. Same expertise level - I'd rather deal with someone who has a reputation of being friendly and caring than roll the dice and hope for the best.

 

[Settledownnow]

I still cannot find any information about Dr.Rabkin and his personality, demeanor, or bedside manner and that concerns me. Same expertise level - I'd rather deal with someone who has a reputation of being friendly and caring than roll the dice and hope for the best.

All of your reasons make sense. However, with regard to Dr. Rabkin's bedside manner, he does have a very good reputation. He is not "out there" publically in the same way as Keshishian. Ask galaxygrrl or go through some of her previous postings. She raves about Rabkin. I have been on the WLS boards for 15+ years and have never read anything negative about Rabkin's bedside manner and care of his patients.

 

[DianaCox]

I’m not sure why you were told that Rabkin does revisions open. In fact, I think there is a major misunderstanding here with Rabkin’s office, which may also explain the vast difference in price - it sounds to me like whoever you’ve been talking to in Rabkin’s office thinks you’re having a revision from RNY to DS, which is a MUCH bigger surgery, and should be done open because of the revision to the stomach. If I understand it correctly, you are just adding the intestinal portion, which can be done laparoscopically. I would call Rabkin’s office again to clarify the procedure and price.

Having said that, I know both men personally. I would put myself in either of their hands in a heartbeat, both with respect to their skills and personalities. You cannot go wrong with either of them - you are fortunate to have two of the best in the world to choose between.

 

[Platti]

All of your reasons make sense. However, with regard to Dr. Rabkin's bedside manner, he does have a very good reputation. He is not "out there" publically in the same way as Keshishian. Ask galaxygrrl or go through some of her previous postings. She raves about Rabkin. I have been on the WLS boards for 15+ years and have never read anything negative about Rabkin's bedside manner and care of his patients.

I should probably clarify - I'm a planner and I gain a lot of comfort in knowing what I'm getting into ahead of time. In my research on Dr. Rabkin, I cannot find many experiences with him. I've read that hes an amazing surgeon which is why I wanted to go with him in the first place but I haven't been able to find many reviews on having surgery with him. His reputation is spotless but I want to be able to talk to someone and get a first hand experience and I haven't been able to find that information very easily.

 

[Platti]

I’m not sure why you were told that Rabkin does revisions open. In fact, I think there is a major misunderstanding here with Rabkin’s office, which may also explain the vast difference in price - it sounds to me like whoever you’ve been talking to in Rabkin’s office thinks you’re having a revision from RNY to DS, which is a MUCH bigger surgery, and should be done open because of the revision to the stomach. If I understand it correctly, you are just adding the intestinal portion, which can be done laparoscopically. I would call Rabkin’s office again to clarify the procedure and price.

Having said that, I know both men personally. I would put myself in either of their hands in a heartbeat, both with respect to their skills and personalities. You cannot go wrong with either of them - you are fortunate to have two of the best in the world to choose between.

I will call to clarify later on this morning but all of the paperwork that I have received so far is correct - I'm having a vertical sleeve gastrectomy to duodenal switch. $15k for surgeon fees, $3k for anesthesiologist, $16.5k for the hospital - $??? depending on if anything needs to be repaired.
The open part is what threw me for a loop and made me a nervous mess so I will clarify with his office on this portion.

If this weren't such an odd time right now, I would go to one of Dr.Rabkins seminars in SF to hear directly from him about the DS and to actually meet him, instead I need to rely on others who can tell me about their experiences.

 

[southernlady]

I will call to clarify later on this morning but all of the paperwork that I have received so far is correct - I'm having a vertical sleeve gastrectomy to duodenal switch. $15k for surgeon fees, $3k for anesthesiologist, $16.5k for the hospital - $??? depending on if anything needs to be repaired.
The open part is what threw me for a loop and made me a nervous mess so I will clarify with his office on this portion.

If this weren't such an odd time right now, I would go to one of Dr.Rabkins seminars in SF to hear directly from him about the DS and to actually meet him, instead I need to rely on others who can tell me about their experiences.

See if you can contact via telemedicine for a question/answer session. You’ll have to pay but it might be worth it.

 

[Larra]

Dr. K is Armenian, but just as awesome as Georgepds describes.