Need serious help getting insurance approval.

Hello everyone,

After researching the various weight loss surgeries I have decided that the original duodenal switch operation is best in line with what I want in terms of weight loss. The problem is that I live in NY, and only the modified version is offered here. After doing research, I found Dr Keshishian in California, who seems to be very credible with alot of experience with the DS operation. However, I am trying to find a way to get insurance approval. I am currently on medicaid and it is highly unlikely that they would approve an out of state operation. I can afford private insurance, but am unsure of how I would go about getting the out of state approval that I need. I thought about getting insurance in California, but I would need state Residence and would have to live there. Any advice on what I could do would be MASSIVELY appreciated.

You're going to the wrong Dr. I also live in NY area and had the Sadi DS almost 7 years ago. It was a fantastic life changing experience. If my Dr only did Sadi DS, I would not recommend him. Your Dr must be fully capable of performing all wls at a high competency level with tons of experience.

My Surgeon was Mitch Roslin at Lenox Hill Hospital in NYC. He handles Medicaid patients and pretty much any medical situation.

I have zero intentions of doing the modified DS as many have made clear that it hasn't stood the test of time the way the regular DS has and you don't get the same extent of malabsorption which is crucial for keeping the weight off. From what i've heard, Roslin doesn't do the original DS

you're actually going to the RIGHT doctor. Dr. K in California (as well as Dr. Rabkin, also in California) are two of the top surgeons in the country for this, from what I understand.

Have you consulted with Dr. Roslin? While recently he has been developing and promoting the SADI, primarily it seems as a mainstream replacement for the RNY, he has long been a strong advocate of the BPD/DS within the ASMBS community. I have also seen discussions online where he had been recommending the RNY for a patient, though that is far from his normal preference - it was, in his opinion (and other DS docs that were consulted as well,) the appropriate thing for that patient's cir****tances, so he certainly isn't a one trick pony. As much as I respect Drs. Keshishian and Rabkin, having dealt with both, if I were in the NY area, I would certainly consult with Dr. Roslin before going across the country, particularly with the insurance complications that would be involved. I may not ultimately go with Roslin, but I would sure want to consider his opinion on my needs.

Does anyone know if Drs. Pomp or Herron are still in circulation, or retired? They are both NYC surgeons who have come up in the past here as being old timers with the BPD/DS, and would also be worth checking out before heading cross country.

It would seem a bit strange to consult with Roslin if he doesn't do the original DS. I have heard from a number of people online that he doesn't, and that is the surgery that im looking for. Im not interested in the bypass due to excessive reports of dumping syndrome, which I do not want. The sleeve doesn't provide enough weight loss for my situation (5'9 310 lbs) and from what I read over on the facebook DS groups the modified version doesn't seem to provide the same malabsorption.

I'm willing to incur higher risks for more weight loss/keeping more weight off long term.

It would seem a bit strange to consult with Roslin if he doesn't do the original DS. I have heard from a number of people online that he doesn't, and that is the surgery that im looking for. Im not interested in the bypass due to excessive reports of dumping syndrome, which I do not want. The sleeve doesn't provide enough weight loss for my situation (5'9 310 lbs) and from what I read over on the facebook DS groups the modified version doesn't seem to provide the same malabsorption.

I'm willing to incur higher risks for more weight loss/keeping more weight off long term.

I would caution you that the SAFI done incorrectly can cause bile reflux which is different from acid reflux. I understand you prefer the DS.
Also , the DS has a sleeved stomach. If you have ever had any kind d of acid teflux(GERD), consider the zDS carefully.
The sleeved stomach can cause new acid reflux snd mske existing g acid reflux worse. Just FYI.

exited to add: do t believe a WORD you read on face book. Nobody on any of those groups knows what they are talking about AT ALL.

I bring up Roslin because I know that he does do the BPD/DS, and has for many years (as HollyKim suggests, don't believe what you read on FaceBook). I mention his use of RNY in a specific case to illustrate that from what I have seen, he is no one trick pony who only knows how to do one thing and that is what they recommend to everyone for every use. Most in the BPD/DS world are not fans of the RNY, as the DS generally works better - that is why they went to the cost and effort to learn how to do them. However, there situations where it is not appropriate (as is the case with any procedure,) so in those rare cases he (and most of the rest of the DS world) is perfectly capable of doing the RNY and recommending it when it is the correct thing for a particular patient. Most bariatric surgeons don't have that flexibility because they don't have as large a tool kit - they don't know how to do much else other than the RNY and maybe the VSG. I like consulting with a surgeon with a broad toolkit because they can suggest something other than their preferred procedure when appropriate without losing business. He knows the DS, as well as the SADI, RNY, VSG, and can discuss their pros and cons for your particular case without a business bias (though he would certainly have his own preferences, as we all do.) You might just learn something that you missed on Facebook. I know a lot more about the RNY than many RNY patients because I have discussed these things with the Rabkins and Dr. K who aren't afraid to discuss the weak points of the different surgeries, including the DS.

Whether you agree with his assessment of your case or not, you will probably learn something, and have more questions that you can ask other surgeons, like Dr. K, whom you may consider. What have you got to lose other than a bit of time - which is usually a good investment when considering a permanent live changing procedure. I am not trying to talk you out of the DS or into anything else, but trying to encourage you to use the resources that you have available to learn as much about all of this that you can. The number of people online that you may interface with have their opinion but generally limited knowledge on these topics (they aren't doctors, for one thing,) so I find it helpful to talk to as many who do know what they're talking about as possible. They have their opinions, too, but they are generally well informed opinions, and that carries a lot of weight (so to speak) with me; much more than the general blogosphere.

I have the highest respect for Dr. K (and he carries off a bowtie very well...) but as I mentioned above, if I were in the NYC area, I would certainly talk to Roslin, and any other local DS docs who are still active, as part of my due diligence. I may well still go with Dr. K, or Rabkin, but by talking to others who may be available to me who are similarly qualified, I will be better informed when making my final decision. One of these docs may see something in you that might give him pause about doing the DS on you - wouldn't you like to know about that before getting into it, or at least being able to discuss that point with others?

You can also check with Dr. Hazem Elariny in Vienna, VA (suburb of DC). I honestly have no idea how insurance would work (sorry) but since I didn't see his name mentioned in this post, I thought I'd add it to the mix. He's a brilliant WL surgeon and he did my DS 18 years ago.

On your insurance question, the best place to get your answer would be to call Dr. K's office and ask to speak to his insurance coordinator. He is a lean operation, but should have someone who specializes in the billing and insurance relations. Explain your situation and questions and they should be able to tell you how reasonable your idea is. He works with patients from all over the country and I'm sure not all of them are self pay, so if there is a way to work out insurance coverage for this, that would where I would start. They would know who in NY they have dealt with in the past and what issues there are (or if it's even reasonable to try.)

Likewise, on the search for a local surgeon, call them and ask - don't just take the word of the FB crowd.

On private insurance, the more expensive it is, the more flexible it generally will be and more likely to be cooperative. The cheaper it is, the more restrictive - limited networks, greater difficulty in going outside of network, fussier on approvals, etc. An HMO, it probably won't fly but a PPO maybe, but you will pay more for an out of network doc than one who is in network.

None of this is quick or easy, so I would work this in parallel with seeking out a local surgeon who does the DS - one of them may well work with your Medicaid coverage and that might be the best of both worlds for you.