Looking into Lap-Band

I am new to the forums and have some questions. First my BMI is 48.  I am diabetic and have hypertension.  I have a hard to getting around due to my problems and now have been disabled for 3 years now due to the depression I have.  I am SICK of living like this and want to get my life back!   I have a 2 1/2 old girl that I WANT SO MUCH to play with and be her daddy.  I now have Medicare via Aetna and have been told that they will cover this surgery.  Does anyone really know what steps I need to take?  My primary Dr is getting me a refferal to Dr Blackstone.   Like I said before I am diabetic and my last A1C was 12.6 which is VERY high.  My sugars are getting out of my control.   Also from what I have been reading this will take 5-6 months for the surgery to happen.  Can I get the going faster because I don't know if I can wait 5-6 months at this point? Any info would help!

Ray, If Medicare is your primary then you may need to do a ONE year medically supervised diet with your pcp (consistently without interruption).  If Aetna is your primary then you may be able to get by with a 3 month surgical multidisciplinary  program which may include all or part ot the following:  weekly visits with exercise physiologist, nutrition counseling, psych counseling, etc.  Often the "to do" list is daunting but if you are diligent and jump through all the hoops then you  will definitely hit the jackpot!  Rare is the insurance that makes wls a piece of cake (so to speak). If you could do self-pay then you could cut through the junk and go straight to the O.R. with most surgeon's.  (cept Dr. Blackstone who is very backed up). Other surgeon's to consider if LapBand is your surgery of  choice: 1.  Dr. Schlesinger (is just re-establishing himself here in AZ and is passionately loved by his previous patients) 2.  Dr. Simpson (specializes in just Lap Band and has great before and after care devoted just to Lapbanders) 3.  Dr. DeBarros (was recently banded himself and has a very successful program) You can check out all of their reviews by clicking above left corner on Bariatric Surgeon and then  moving your curser over the state of AZ. Programs tht "mix it up" are of course Scottsdale Bariatric w/ just Dr. Blackstone and Bridges St Luke's who has Dr. Fang and Dr. Juarez. Hang in there!  Your darling daughter needs a healthy, active daddy!!!!  .......Warm wishes your way that it all goes smoothly!  Give us a shout if you need help along the way!

Well I had to choose which insurer to get this year with Medicare.  I chose Aetna.  I have called them and they stated that they use Medicares guidelines.  I can not really get any clear answers but I found this on the net:

The Centers for Medicare and Medicaid Services (CMS) issued its long-awaited national coverage policy for bariatric surgery on February 21. The new policy extends bariatric surgery benefits to all Medicare recipients.

Previously, Medicare covered gastric bypass surgery only if the procedure was intended to correct an illness caused or aggravated by obesity (DOC News, January 2005). Coverage for the operation varied from state to state in the absence of a national coverage policy.

Under the new policy, CMS covers open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic biliopancreatic diversion with duodenal switch. CMS will not require that candidates for bariatric surgery first attempt a dietary weight-loss program, as almost all surgery patients have made numerous weight-reduction attempts.

Bariatric surgery is available for any Medicare beneficiary with a body mass index 35 with at least one comorbidity related to obesity.

Coverage is provided only if the bariatric surgery is performed at a medical center designated a Center of Excellence by the American Society for Bariatric Surgery (ASBS) or certified a Level 1 Bariatric Surgery Center by the American College of Surgeons. As of February 28, 2006, there were 117 Centers of Excellence in 32 states. ASBS expects that number to nearly double within the next few months.

The new Medicare policy has positive and negative aspects, says endocrinologist Michael Jensen, MD, executive director of Shaping America's Health: Association for Weight Management and Obesity Prevention.

Limiting reimbursement to certified groups and medical centers "is going to be problematic" for surgeons who aren't able to meet Medicare standards, Jensen says. But more important is "the imprimatur that [bariatric surgery] is an effective treatment."

Bariatric surgery is "the only effective treatment for a fatal illness," says ASBS President Neil Hutcher, MD. "Bariatric surgery saves lives, treats diabetes, and improves sleep apnea and hypertension."  ^{So does this mean I need to wait this long?}

Hi Ray. First of all I want to say congratulation on your choice to have the surgery.  You are doing it for all the right Reasons.  I have little ones too, and i want to be here for them.  My insurance wanted me to do a 3 to 5 year plan and i just don't have that, so i have chosen to self pay.  As scary as that may sound, 75 percent of the lap banders in Az seem to be self pay.  it sounds like you are really doing your Homework with your insurance.  Don't give up and push if you have to.  I suggest that you contact a few Docs.  Go to their seminars.  They all have great office staff that will be able to help you with your insurance questions because thats what they do. I choose  my Doctor because he was kind and skilled. i know he cares about me and my success.  he was the right fit for me.   This site is loaded with helpful supportive people who are going through or have gone through it already.  You are your best advocate.   Be strong Ray, you can do this.  This is where you belong. 

Thanks for kind words.  One thing I am is a fighter when it comes to my rights and my family.  My wife can back that up for me. Anyways per the Evidence of Coverage doc from Aetna I found this:

"Weight control services including surgical procedures, medical treatments weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications, food or food supplements, exercise programs, exercise or other equipment and other services and supplies that are primarily intended to control weight or treat obesity, or for the purpose of weight reduction except to the extent covered by Medicare." So my take is Medicare should cover because of the post I made before.

I am so glad Medicare changed their guidelines and just in time for you!  Like the previous poster, attend several seminars to find a good doctor "fit".  Be sure, however, they work in a Center of Excellence.  Those centers meet stiff criteria for the certification from the training of the doctors and staff, the number of procedures done per year and even the furniture available for the obese patient!  Shea Scottsdale is a Center of Excellence and Dr. Blackstone heads their bariatric department.  Her wait is long.  I understand she is currently scheduling for January 2008.  Research the different surgeries.  I notice you wanted lap band.  There are so many types of WLS available and you want to have the one that will provide the most likely success for you especially with your health conditions.  I think you will find everyone thinks their doctor is the best.  That is how it should be.  Find the best for you!  Good luck.

Dear Ray, I am very happy for you on your choice to have this miraculous surgery,  My surgeon is Dr. Blackstone also because I am on Medicare through Humana and their office is only one of two in our area that are rated as a center of excellence...BUT...I would want to go to her anyway.  Her staff and program are phemomenal!  I had to jump through a lot of hoops with insurances and guideline changes too.  Dr. Evershad works with Dr. Blackstone and she did my surpervised dier program for 6 months.  She's great and very compassionate and helpful. I would suggest you read a book by Paula Peck, called "Exodus from Obesity".  A friend here recommended it to me months ago and it outlines EVERYTHING you need to know about RNY surgery - Pre-op and Post-op. I am having my surgery this week on Thursday.  I am excited, nervous, scared and HAPPY!  I have had a weight problem all of my life and my BMI is about 40.  Like you, my blood sugar levels began to rise and now I am a type 2 diabetic.  My cholesterol levels way up over 200.  My body aches all the time because of the extra 100 pounds I carry around, and I also have a 4 year old Grand Daughter that always wants to play with Grandma.  Well, I want to be around to do that, and more! You will not have a choice on the 6 month waiting period UNLESS you can document that you have already had some type of physician supervised diet (attempt) that covers a 6 month period with no breaks...it has to be consecutive months. There are quite a few tests that need to be done in the meantime, so get started as soon as you can. You will be another success story on Dr. Blackstone's "Wall of Fame"! Good Luck and God Bless. Robin

Is this 6 months waiting something Dr Blackstone requires?  As per Medicare the 6 month dieting is not required anymore.

I completed my 6 month doctor supervised program in April.  At that time it was still required by Medicare.  Dr. Blackstone does not have any time requirement that I know of.  Her staff will schedule you as quickly as time permits. Robin

Right now I am not sure if I am going to be using Dr Blackstone or Dr Villares.  My wife and I will be going to both semiars next week.  From what I have read in their reviews they both seem good.  I think maybe who can setup the surgery first might be who I see.  We have a Xmas trip planned for Disney these year and I would like to have had the surgery and time to recover before we go.  This will be my little girls (2 1/2) first time.  I pray that I will be able to ride some rides with her!