Horizon BCBS NJ Says NO / BMI TOO HIGH????

edited for spelling and typo I had surgery by Dr. Dennis C. Smith of Marietta, GA. I flew to him from Seattle, WA cuz he said he'd do the DS all-in-one-surgery on me, and my BMI at the time of surgery was 73.1.  I came through the surgery without a hitch. Dr. Smith is very careful, and very selective. I had severe sleep apnea, high blood pressure, depression, osteoarthritis, and borderline diabetes. I was also taking an ACE-inhibitor because I'd had some sort of "cardiac event" the autumn before. I'm suspicious of Horizon BCBS of NJ. Sounds like, to me, they arelooking for any excuse to turn you down, as this is a very costly surgery.  Have you searched the NJ state OH board? Or perhaps searching on individual profiles of those who have had bariatric surgery in NJ would help? I wish you good luck, and I hope your situation gets cleared up soon. Know that I know where you're comin' from. ~ anne s.

Sorry to noodge you again, UncleFluffy, but I was wondering if you'd considered having the Duodenal Switch.  There's good empirical evidence for those with a BMI over 60 that the Duodenal Switch is the most successful of all the available weight loss surgeries at this time.  My profile has links to explanations of the DS, and also shows the published medical study that found the above to be true for us bigger bigguns (over 60 BMI).  PM me anytime, and please take a look at my profile, there's lots of info there... Again, my best, anne

Perhaps its the type of surgery you're asking for.  Higher BMI's need more drastic measures.  The Duodenal Switch is MOST RECOMMENDED for those with the higher BMI's (but anyone with a BMI of 40 can get it too), because it has the highest percentage of weight loss success.

There are several studies showing that the duodenal switch is especially effective with BMI's >50.  You may need to find a DS surgeon to help you in this life saving battle.   If you want more info go to duodenalswitch.com, and over to the DS forum here.   On the DS forum you'll find an extraordinary woman, she's an attorney, and a PhD in some science field--can't remember which.  She's a barracuda and I don't think anyone knows more than she about how to effectively do battle.  Her name is Diana.  Just post there with "Help! Diana"  and she'll get back to you ASAP.  She checks in quite often. Please don't despair.  You've had enough of that in your life.  Have hope, faith, courage, and I'm confident you WILL prevail.  

What you do next is APPEAL (and/or hire an obesity attorney gary viscio).  I dunno where you live (NJ?), but MOST states provide state reviews of insurance company denials.  So, complete the required appeals with your insurance company and then if they continue to deny, appeal to your state's (NJ?) insurance commission.  And while you're fighting, you might as well be fighting for the "BIG GUN" surgery -- the DS.  You can find a lot of insurance warriors on the DS Forum here on OH.  Here is the link where to find us.  We'll hold you hand every step of the way:

http://www.obesityhelp.com/forums/ds/a,messageboard/board_id ,5357/ 

Uncle Fluffy I have the same insurance, and they (like others I have heard) pull this BS, because they think you're at too high of a risk for complications and they don;t want to pay for that. Listen, ANY surgery at your BMI is going to be riskier, but if you needed a CARDIAC bypass to save your life they wouldn't say "no." The DS is DESIGNED to treat the high risk, high BMI  patients.  Since the Sleeve  is probably the SAFEST WLS out-there, they start with that. They've been removing partial stomachs (and full stomachs) for decades, and know it has an excellent SAFETY profile. This is why surgeons, like De. Gagner and the group at NY Presbyterian/Cornell/Columbia, and others, started this procedure. They knew it caused people to lose weight, even if they had part of their stomachs removed for other reasons (ulcers, cancer). Then, once you have lost about 100 lbs or so, or about 12-14 months later, they do the second part--the bypass-- and the DS is what most docs do for the second part. It's staged in too parts because it is SAFE. Also, over the years with the 2-part VSG/DS, many who had just the Sleeve were not wanting or needing the 2nd part. That's why they started looking into it as a Sole, stand-alone procedure. The results show it is comparable to the RNY (and far superior to the Band) after yrs 1,2,and 3. There's some 5 year data showing some wt regain with people who had higher BMI's before surgery. And those, like yourself, may very well need the second part to lose it all. The DS has excellent results, but the second part may not be needed by all who seek it. Many wait and see. I think the sleeve and DS are better than the RNY because the RNY pouch can stretch so much more. The Sleeve (alone or as part of the DS) makes the stomach out of the LEAST stretchy part of the stomach. Lots of RNYer regain, but the Sleeve doesn't strretch too much. And if it does, it stretches up at the top (they place where the RNY pouch would start). It's my understanding that Horizon BC/BS HAS approved the Sleeve and the DS on an individual basis. Many BC/BS around the country are starting to, as there is a push to get the "experimental" title removed due to such promising research. Check DS and VSG board for articles to use to fight with. It may be that for the RNY (which really is a drastic surgery) isn't safe, and that's why you were denied. If you submit for the 2-part DS or the Sleeve alone, it is much safer  and you may therefore get approved. Although I prefer the DS, and think you'll have better results, if you really wanted the RNY, you could get the Sleeve first to loose enough weight and get the RNY bypass (using the sleeve stomach instead of the pouch) later if needed.  That way you'll be less likely to stretch. I know all this is confusing. You can contact the NJ Commission on Banking and Insurance in Trenton. They have a web site and you can call and ask some questions. Although they are lawyers there, they try not to give legal advice til they receive a complain form. Tell them you need some direction on whether you have a reasonable complaint and see if they can guide you. Remember, whoever you get on the phone may not know the details of WLS. Good luck and keep us posted. Don't let the *******s get you.  HORIZON BC/BS Kahlua

I would like to thank you all for your kind and informative replys. I knew nothing about the DS procedure. I now have loads of homework to do researching this as a possible option. I will NEVER give up this fight for my life! I've said this before. "Even if I die on the operating table, I will feel alot better then I do right now"  Wishing you all a BLESSED Christmas and a Happy New Year. All My Best -MIKE-