I had DS - maybe my 18 y/o son could too? Also, Q for Diana Cox
My son, 18, getting a DS? I don't know if he could handle it. Then I think, what happens at 25, 30? Do I think he'd be ready then? And I still think no, so I wonder if I just feel so protective of him that I would never think he's ready. This is my baby we're talking about here.... :)
Diana - I'm going to paste in the rider. Can you glance through it and let me know if it looks like the DS is included? I understand there is a precertification, but it looks like there is some weird rules around VSG, but not sure if that means the DS too in the way its written.
Thanks everyone!!
Policy Number:
MM.06.003
Section:
Surgery
Place(s) of Service:
Outpatient; Inpatient
Line(s) of Business:
HMO; PPO
Original Effective Date:
09/11/2001
Current Effective Date:
03/01/2011
I. Description
A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as patients with a body mass index (BMI) of greater than 40 kg/m² or greater than 35 kg/m² in conjunction with severe comorbidities such as cardiopulmonary complications or severe diabetes.
Super obesity is described as a BMI of greater than 50 kg/m². The American Society for Metabolic and Bariatric Surgery (ASMBS) defines super – super obese as a BMI of greater than 60 kg/m 2.
The ASMBS, in a position paper on laparoscopic vertical gastrectomy/ gastroplasty, states while the procedure is safe and short term data (5 years) are promising and comparable to other covered procedures, data on long term health outcomes are not yet available.
II. Criteria/Guidelines
- Surgery for morbid obesity is covered (subject to Limitations/Exclusions and Administrative Guidelines) for members when the following criteria are met:
- The patient is morbidly obese, defined as either of the following:
- Persistent and uncontrollable weight gain that constitutes a present or potent/ial threat to life,
- Weight that is at least 100 pounds over or twice the ideal weight as described in the Metropolitan Life tables; or
- A BMI greater than 40 kg/m²; or
- BMI of between 35 and 40 kg/m² with one of the following high-risk comorbidities:
- Severe sleep apnea (defined as repeated hypoxia with oxygen saturation less than 80% on sleep study; or documented pulmonary hypertension on echocardiogram or right heart catheterization; or sleep apnea induced right heart failure requiring hospitalization).
- Pickwickian syndrome
- Obesity-related cardiomyopathy
-
Diabetes mellitus with evaluation and recommendation for surgery by a multi-disciplinary team with expertise in weight, metabolic, and diabetic management and which is part of a comprehensive weight management program associated with the facility that will perform the operation.
- Persistent and uncontrollable weight gain that constitutes a present or potent/ial threat to life,
- The surgery is intended to achieve one of two results:
- Alteration of the mechanics of food absorption; or
- Alteration in the volume of food ingested.
- There is documentation that the patient's efforts to lose weight have not been successful.
- The patient is morbidly obese, defined as either of the following:
-
Laparoscopic longitudinal gastrectomy (i.e., sleeve gastrectomy) will be covered for patients who have a BMI of greater than 60 kg/m2 or for patients who need to maintain GI continuity with the duodenum (e.g. for tumor surveillance), or when they meet the criteria in II.A above and have documentation in the medical record that laparoscopic Roux-en-Y bypass is not possible.
- Revisions, replacements, and re-dos of bariatric procedures will be covered if the patient met policy criteria at the time of the initial procedure, and there is documentation of a medically significant complication or failure.
III. Limitations/Exclusions
- Lap band procedures must be performed in the outpatient setting unless the physician is recommending the procedure be done in an inpatient setting. When requesting pre-certification, the physician should outline concerns about the member's comorbidities, complex problems, age considerations, etc.
- Lap band procedures are not appropriate for II.A.1.b.
IV. Administrative Guidelines
Precertification is required. To precertify for procedure and place of treatment, please complete HMSA's Precertification Request and mail or fax the form as indicated.
Click for Metropolitan Life Tables
| CPT Codes | Description |
| 43644 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) |
| 43645 |
with gastric bypass and small intestine reconstruction to limit absorption |
| 43770 | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g. gastric band and subcutaneous port components) |
| 43771 |
revision of adjustable gastric restrictive device component only |
| 43772 |
removal of adjustable gastric restrictive device component only |
| 43773 |
removal and replacement of adjustable gastric restrictive device component only |
| 43774 |
removal of adjustable gastric restrictive device and subcutaneous port components |
| 43775 | longitudinal gastrectomy (i.e., sleeve gastrectomy) |
| 43842 | Gastric restrictive procedure, without gastric bypass for morbid obesity; vertical-banded gastroplasty |
| 43843 |
other than vertical-banded gastroplasty |
| 43845 | Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) |
| 43846 | Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy |
| 43847 |
with small intestine reconstruction to limit absorption |
| 43848 | Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) |
| 43886 | Gastric restrictive procedure, open; revision of subcutaneous port component only |
| 43887 |
removal of subcutaneous port component only |
| 43888 |
removal and replacement of subcutaneous port component only |
| 43999 | Unlisted procedure, stomach |
| HCPCS | Description |
| S2083 | Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline |
V. Important Reminder
The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician.
Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.
This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA’s determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation.
VI. References
- American Gastroenterological Association. Medical position statement on obesity. Gastroenterology. Sept. 2002; 123(3):879-881.
- Medical Policy Reference Manual. Blue Cross and Blue Shield Association. Surgery for morbid obesity. Policy #7.01.47; January 2010.
- Blue Cross and Blue Shield Association. Technology Evaluation Committee. Bariatric surgery for morbid obesity. 2003.
- Blue Cross and Blue Shield Association. Technology Evaluation Committee. Laparoscopic Adjustable Gastric Banding for Morbid Obesity. February 2007.
- Blue Cross and Blue Shield of Massachusetts. Policy #379. Medical and surgical management of obesity. March 3, 2010.
- NIH Consensus Development Conference Statement. Gastrointestinal surgery for morbid obesity. March 1991; 9:1-20.
- The American Society for Metabolic and Bariatric Surgery. Updated position statement on sleeve gastrectomy as a bariatric procedure. Revised 2009. Surgery for Obesity and Related Diseases. 2010 Jan-Feb 6(1):1-5. Position Statement.
To refer to the previous version of this policy, see Bariatric Surgery - OBSOLETE2 .
He really wants to do it, but like I said I'm confused about my feelings of thinking he can handle it or not. Ultimately, it is his decision and I will support him regardless. I am worried my big mouth might get in the way. What might be some good questions to ask an 18 yo to see if they are really ready for that responsibility?
You're right about the BMI not being high enough. He will have to get properly diagnosed, but I am fairly certain he has sleep apnea.
I thinks Diana has answered some of the age/weight issues rather well ( post just below).
My gut says wait until he's older. My son at around 16 (now 35) went from 295 (football playing weight) to 218 ( basketball weight) in a few months and has never had a weight issue since. He obviously doesn't have my weight issues/genes.
-Gail-SW 257 CW 169 GW 165
Technically, it appears the DS is covered, if the patient qualifies for bariatric surgery. I don't see a requirement for proof of 5 years of continuously being MO. I don't even see an age limitation. They are limiting the VSG, however, to SSMO and those who have a reason to not have RNY. And they are, I think (because the numbering got screwed up in your post), limiting the lap band to BMI < 40.
But something for you and your son to consider - his BMI is 36.2. Unless he has a comorbidity, why on EARTH would you consider a DS for an 18 year old boy (and boys are not even fully grown until their early 20s) who is as far as I can see, capable of adding some exercise and moderate dietary restriction (like getting rid of the sugar and white carbs) without resorting to surgery?
I'm not understanding your POV. I don't know why you would consider a DS for a young kid with no comorbidities who is ~75 lbs overweight and has no discernable obstacles to a more conservative approach.
My daughter, who is almost 29 and has a BMI of about 34, was interested in the VSG. I could pay for it for her. A reputable surgeon I know would do it for her. But she hasn't had kids yet, and after discussion with her and the surgeon, we concluded that she should wait - her weight will probably go up, especially if she has a couple of pregnancies, but there is no NEED to do this now. (And this includes consideration of her back and knee problems, which result from a minor congenital problem with one leg, which her weight makes a bit worse.) If she does the VSG now, and then goes through a couple of pregnancies, where will she be in 5-7 years? Needing a DS AND a resleeve?
It is my fervent hope that in a few years, there will be a pill that operates on the gut receptors to induce similar changes to metabolism that the DS does. I would avoid surgery for young people with minor weight issues if at all possible. SMO - of course don't wait. BMI 40-45? Consider it, but not without a good medical reason. And never, under ANY cir****tances, consider the lapband.
When I did his BMI calc I was SHOCKED how low it was. His body hurts from his weight, it’s hard for him to move. He is embarrassed of his weight of course and lack of mobility. As his mother, I want to get him the help he needs as soon as possible, but also as soon as appropriate. I don't want him suffering for years, the mental degradation as his weight gets higher, the sadness and internal battle that comes with it. I hope this is making sense and the right intention - typing this stuff out with meaning can be so hard. I really do need advice at this point because I want to guide him to make the best choice possible. I don’t need my one remaining brain cell making hasty decisions and pushing him in the wrong direction. He sees me as his living example, a success even, and it’s hard to deny him the desire of the same option.
Sorry about the numbering in the post - my screen is showing it perfectly or would try to fix it.
The first time I ever heard or saw the word obese I had a school physical, I was 8 or 9. I saw the word on the physical report and asked my mom what it meant. I know the damage being an overweight child and teen can have, saying all that, the responsiblity of DS is too great for an 18 year old. I'm almost 50 and think it's a huge reponsibility for me, I would be dead if I'd tried it at 18.
He has college, getting drunk all the things yet to do. I'd be afraid he would "forget" about vitamins during those times. One of the hardest things a mom has to learn is that our kids aren't us...they have their own paths. You can't spend the next 10 years till he is reponsible reminding him to take vitamins...when he has a child and isn't make enough money for diapers and his vits...what is he going to do...kids don't come with instructions or crystal balls...give him enough time to mature.
1985 Verticle Banded Gastroplasty to DS revision 2010 sw 280 gw 140 cw 188 hw 360
“If the person you are talking to doesn't appear to be listening, be patient. It may simply be that he has a small piece of fluff in his ear.?
Winnie the Pooh
I believe that some people are capable and mature enough to handle the DS at his age, or even younger (remember Jesse from Alaska, DS at 16 and has done great), some are not. Some people are not ready for the DS at any age. Some people are never ready for ANY form of wls. You know your son. We don't. Is he a mature 18? Is he responsible and dependable? Would he take the vitamin/protein/mineral requirements seriously and make a lifetime committment?
And all that is aside from the great points Diana and others made about his bmi being relatively low.
But I'm also someone who grew up fat, though not MO, and I totally understand both his desire to experience your success and feel better, and your desire for health and happiness for your son, as you see him suffering NOW.
So I don't have an answer for you, just hope you will take into account not just his age but his maturity level, and if still in doubt would recommend arranging a consult for him with a reputable DS surgeon to get that perspective as well.
Larra
