Fighting for the procedure I want

Hello, all!

Thanks to Herman, who suggested I bring my situation up here. :) I have a question and could use much input.

I have been battling excess weight my entire life. I have failed no less than 5 diets. The most I have lost was about 95 pounds, (I was in my 190s) and it stalled and nothing I could do would get it moving again. I quit smoking, stopped dieting and gained almost everything back. I'm currently 260 lbs with a BMI of 40. I have chronic trochanteric bursitis and osteo arthritis. I strongly resemble my father, who has been morbidly obese for as long as I can remember, has had 2 arterial bypasses and is currently fighting type 2 diabetes.

My mother told me about the wonderful results a friend of hers is having with her Duodenal Switch. I called Dr. Daryl Stewart's office inquiring about DS. The person who prescreened me said that in order to qualify for DS I would need a BMI of 50 or more. This was disappointing, but it got me researching all the options, which I probably should have done to begin with. ****il hearing about DS, the risks of surgery didn't really seem to be worth the benefits, except that now I realize how rare it is for someone like me to lose weight on their own, permanently.)

I have read everything I can find on WLS, watched Dr. Stewart's seminar video, and gotten feedback from quite a few folks right here in the ObesityHelp forum. All this has led me to the conclusion that I really do want the DS. I feel it's the best choice for me given my family history, and personal co-morbidities. I have an appointment with Dr. S two weeks from tomorrow.

Now I've spoken directly with my insurance company and all the representatives there could tell me was that bariatric surgery was covered. They couldn't tell me anything about DS specifically one way or the other. I don't know if the 50BMI is a requirement of Dr. Stewart's or whether the fella at his office just presumed my insurance required it, but I intend to fight for DS. If I fight and lose, I'll opt for the sleeve, but I'd much rather get the most effective surgery for both weight loss AND diabetes up front.

Thank you for reading this far! Whew! 

My question to all of you here is this: What should I do to prepare for my meeting with Dr. Stewart that will give me the best case for getting DS at this point? I already plan to put together as complete a medical history as I can, write a letter enumerating the reasons I want DS, and a list of questions for Dr. Stewart. Is there anything I'm forgetting? What questions would be good to add to the list?

You may want to see if you can get a current document from your insurance company outlining what will qualify you for WLS and what they will use to deny you. If there is no 50BMI requirement, a BMI over 35 with 2 comorbidities, that they define, may be enough. Blue Cross Blue Shield is notorious for their ridiculous "documented 50 BMI for the last 5 years" requirement.

When you weigh-in at Dr Stewart's, wear your best boots and ankle weights. Who knows, maybe you're under-estimating your weight.

--gina

 I like the way you think!!

If he waffles about the over 50 BMI (and my first surgeon only did the DS on those over a 50BMI) then pull out all the info you can as to why it's best for you....AND be willing to suggest a longer common channel. That's mainly how I got Dr. Boyce willing to do mine. I knew all the reasons I should have it and let him know I was willing to go with a longer common channel to get the DS.

Liz

I have never heard of Dr. Stewart's office requiring a BMI of 50 in order for him to agree to performing a DS... I would be very surprised if this is now true.

I agree that you need to investigate your insurance coverage a bit more.  I would call the number on your card for customer service and inquire if bariatric surgery for CPT code 43845  (biliopancreatic diversion with duodenal switch) is covered.  Ask them to email you or give you the URL where you can download your medical policy's coverage statement for bariatric surgery.  It is only HERE that you will see your requirements.  In fact, I was told by one DS surgeon's office that a 6-month supervised diet was required and that I would have to attend nutritional counseling.  My medical policy statement said nothing to that effect.  

If they try to ask for more than the policy states, call them on it.  Make them show you where it states that.  Set the stage for them to say "this one's not going away..."

Good luck!  Report back!

If your policy allows for bariatric surgery, the insurance company's coverage guidelines then kick in.  Insurance companies almost all have their coverage criteria online.  Here, for example is CIGNA's.

http://www.cigna.com/assets/docs/health-care-professionals/c overage_positions/mm_0051_coveragepositioncriteria_bariatric _surgery.pdf

They do require a BMI over 50 for DS.  Your company should have something similar, available. To find it, Google the name of your insurance company and weight loss surgery coverage (i.e., "Cigna Weight Loss Surgery Coverage).

Good luck! I hope you get you your DS, and you may want to consider self-pay.  FWIW, I love my sleeve, but I would not settle. I have CIGNA,  but I self-paid because I didn't meet their criteria at the time. It has since change removing some weight documentation requirements and shortening the doctor supervised diet period.

My insurance company is CIGNA and it looks like that link is word for word what they were reading to me on the phone. I wonder why they said they didn't have a URL to give me for it? Weird.

Ok, It looks like my history with WW is too old to meet their qualifications. I sure hope this doesn't mess up my coverage. 

The last time I was this certain about anything this huge, it was marrying my husband - and that worked out beautifully!

Thanks, everyone!

I just got off the phone with CIGNA. The qualifications for DS are no different than RnY or LAP BAND with them. Whew! One hurdle down.

I'm a little worried about my diet history... The only diet I was on that was admissible to qualify me was Weigh****chers. But that was mostly online and I don't know what kind of documentation will be required. Chugging right along, though.

Update: Just got off the phone with weigh****chers. They reactivated my account to let me print my weight history from their database! Very nice of them. I hope it's enough.

Really think about it.  Have you ever done low carb, low calorie, or things like Slim Fast?  Like you, I really only did WW online, but once I went to the nutrionist (my ins required 3 months of nutrition counseling) she was able to point out that my way of "fad" eating could be considered a diet.  Regardless, you will probably have to do some sort of nutrition counseling and that will be documented.  Really go back and try to remember the "diets" you have done over the course of your life.  You may not have done Atkins or South Beach, but you probably did something.

Oh, I've done *lots* of things, it's just that the insurance representative said that it had to be something documented or under doctor's supervision, and the only thing I've done that resembles that was weigh****chers. Well, that, Jenny Craig, and LA Weight Loss, but those other two were over a decade ago and getting documentation from those could be difficult.

I've also done The Zone, and a low GI/low carb diet, but that was 100% on my own.