Insurance says DS investigational: a how-to manual

My advice is the same as the advice above -- please feel free to contact me.

I followed all of Diana's steps and am scheduled for surgery next Thur with Dr Rabkin.  Kaiser did deny me both at local and regional level even saying that the RNY and the LapBand were just as good for my diabetes and weight loss as the DS.  I made sure that I'd had my DS surgeon & psych consults done paid out of pocket.   I'd been to several user groups and seminars.  I'd poured through several IMR's to see what had tripped some folks up with not being overturned and wanted all my ducks in a row.  It worked.  Thanks Diana!!! 

Read twice, printed out and bookmarked ! 2 great posts within 24 hours.... your's and Lori's.  

Diana, Though I didn't have to fight for my approval. I will place this information on my Profile to further filter the information towards those who need to know!  Trying to Pay It Forward ASAP! Awesome Post!

Hi Diana!

You're awesome!  Thanks so much for all the great info you've given us!

I called my insurance company Blue Cross Blue Shield and had them email me a copy of their guidelines for coverage for gastric bypass, which they did for me. That way I could read everything for myself.

I'm wanting to get the DS procedure.  I read the guideline document that they sent me and the way I read mine, it is covered.  It specifically lists the DS along with lap-band and RYN.

I pasted what it said below.  But, since my policy specifically lists the DS procedure, I should be fine then, right?  What do you think?

Thanks!
Tracy

Medically Necessary:

Gastric bypass with a Roux Y procedure up to 150 cm, laparoscopic adjustable gastric banding (the Lap-Band^{® System), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered} medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet the following criteria:

 

Looks good to me!

Hey!  It's me again! 

I was also wondering if anybody can understand by reading my policy guidelines if the 6 months of diet class/counseling is required?  I mean, mine lists that diet counseling and evaluations be done, but doesn't list anything specific about how long or anything like that. 
So, just wondering what that would mean then, if anybody knows?

I pasted the info below that is in my policy.

Thanks again!
(I just love this message board & the people here)

Tracy

The patient’s post-operative expectations have been addressed;

 The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate;

 The patient has undergone a preoperative mental health assessment and is felt to be an acceptable candidate;

 The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure;

 

 

The patient’s psychiatric profile is such that the patient is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements;    The patient’s treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; The patient’s treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.    

Make sure your surgeon's office gets a copy of these policy guidelines and addresses EACH AND EVERY ONE OF THEM in their letter, and how you meet them.  Tell your surgeon's office that you want to REVIEW their letter before they send it, because you want to make sure that all the "t"s are crossed and "i"s dotted.

 What wonderful information! I must tell you that the amount of time you spend helping pre-ops like me is immensely appreciated! I'm sure the amount of lives you have changed is immeasurable.

I was wondering if you can help me find documentation that proves that the DS should not just be performed on the SMO, and works just as well for us "lightweights". I have checked out the dsfacts, duodenalswitch and lab rats websites, but was wondering if there was anything that specifically documented the effectiveness of the DS on BMIs of the MO. My BMI is 42 and the Bariatric Institute told me yesterday that usually the DS is performed on BMI of 50 to 60+. I know that this facility does do the DS and think if I can argue my case with them, they will perform it for me.

I want to give them specific data to back me up.

Thanks!
Jules

http://files.meetup.com/379062/DUODENAL%20SWITCH%20LONG-TERM %20RESULTS.pdf

There is also this paper, which is not available online, but I have a copy at home.  PM me your email address and I will send it to you.

Surg Clin North Am. 2005 Aug;85(4):819-33, viii. Links

 

The duodenal switch operation for morbid obesity.

Anthone GJ.

Bariatric Surgery Program Physicians Clinic, Nebraska Methodist Health System, Omaha, NE 68114, USA. [email protected]

The duodenal switch provides excellent weight loss with preservation of good alimentation, even in the superobese. This is accomplished with acceptable operative mortality and minimal dietary limitations and metabolic sequelae. The results of the duodenal switch that are reported in the literature should remove any inhibitions that exist about the use of this procedure as treatment for patients who have morbid obesity. This article discusses the duodenal switch operation for morbid obesity.