DS Investigational
Lap band- Aug 2006 - 254lbs.
Lowest w/band 214lbs. .
Gained up to 271 due to the band
Got DS revision April 2010!! Current 145lbs
At 5'8 my goal was 160lbs but I surpassed that with the DS!!!!!!
on 8/21/09 12:55 pm - Tuvalu
Hi Datrace -
Future DSer here! Don't get discouraged!!! The DS is now covered by Medicare, which means that most major commercial insurers should also cover it. You may still have to jump through their hoops and appeal appeal appeal. But it should ultimately be covered, as most insurers base their policies on Medicare standards.
Here's what the Centers for Medicare and Medicaid Services (CMS) added to their policy on 02-21-06:
"Effective today, the list of nationally-covered procedures now includes open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic biliopancreatic diversion with duodenal switch. "
www.dsfacts.com has a most excellent How-To manual by Diana C. (who posts frequently on the OH DS forum) with advice on what to do if you "run into the insurance roadblock of the DS being deemed experimental or investigational". I tried to copy the thread from the website, but it didn't work... There's a link on the home page of the dsfacts.com website.
Also, just in my opinion, I wouldn't consider any other WLS than the DS - it has the highest success rate for total excess weight loss, the highest success rate of maintaining weight loss over a 10-15 year period, and you get to eat more normally than any of the other surgeries. I don't consider that a drawback!!! You're lucky you have a doctor who's informed and recommending it so passionately! Check out dsfacts.com and the DS forum here and see for yourself! 
Whichever surgery you choose - best of luck!!!
Laura
"...I have BCBS of Illinois and the 5-year weight history was still required under my PPO plan as of Feb 2009 (when I submitted for approval). I had to go thru a 6-mo weight loss program as well. I had to fight to get my surgery; two denials, two appeals. It was horrendously stressful. And get this: the 2nd denial was for an incomplete 5 yr weight history! I was lucky in that I remembered one emergency visit and that's the only thing that got me over that argument. I really would have been ticked if I hadn't remembered it & been able to get that record (which had been sent to storage no less), and BCBS denied me again and then have a policy change only 5 months later..."
Laura
on 8/21/09 1:54 pm - Tuvalu
For example, Medicare's take on what is experimental is as follows:
Experimental and investigational treatments and procedures are those medical treatments and procedures that have not successfully completed a Phase III trial, have not been approved by the FDA and are not generally recognized as the accepted standard treatment for the disease or condition from which the patient suffers.
Experimental and investigational treatments include off label therapies. Off-label therapies are those medical therapies that use a FDA approved drug or procedure for a non-indicated use. Also, these Experimental or investigational medical and surgical procedures, equipment, and items or medications, are otherwise not covered by Original Medicare or covered under qualifying clinical trials.
But, since, medicare pays for the DS, as do Medicaid and most Federal Employee Insurance plans and TriCare, it is FAR from experimental. In fact, the procedure is performed at many VA hospitals and is covered by many other insurance companies, including other BC policies.
I would also mention that other BC policies have declared the DS to be an established procedure and NOT experimental. For example, Anthem BC in California says:
| Position Statement |
Medically Necessary:
Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band® System or the REALIZE™ Adjustable Gastric Band), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria: (and then they list the criteria)
And then they say:
| Rationale |
At this time, there is sufficient evidence in the peer-reviewed medical literature to support the use of gastric bypass with a Roux-en-Y procedure up to 150 cm and/or vertical banded gastroplasty for the indication of clinically severe obesity. The evidence suggests that these procedures are beneficial for this indication in a selected group of individuals. The most compelling evidence for an improvement in comorbid conditions comes from the Swedish Obese Subjects (SOS) intervention trial that reported a large reduction in diabetes over a 5.5 year mean follow-up for the surgery group. While there is substantial evidence that these procedures can facilitate significant weight loss and improve co-morbidities in clinically severe obese individuals, perioperative mortality may occur in such individuals as well, occurring at a rate of approximately 1 in 200 procedures. In order to minimize potential morbidity and mortality, individuals who undergo such treatment should meet specific criteria prior to undergoing the procedure. The evidence supporting this conclusion includes properly randomized controlled trials.
There is also sufficient evidence to support the use of the biliopancreatic bypass with duodenal switch for individuals who have clinically severe obesity. Mortality is similar to the Roux-en-Y procedure, and the evidence suggests that up to 70% excess weight loss (EWL) can be maintained over long-term follow-up (up to 6 years post-surgery). The evidence supporting this conclusion includes multiple large case series.
And then...they describe the DS:
2. Biliopancreatic Bypass with Duodenal Switch
The duodenal switch procedure is essentially a variant of the biliopancreatic bypass described above. However, instead of performing a distal gastrectomy, a "sleeve" gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum to create the alimentary limb. Preservation of the pyloric sphincter is designed to be more physiologic. The sleeve gastrectomy decreases the volume of the stomach and also decreases the parietal cell mass, with the intent of decreasing the incidence of ulcers at the duodenoileal anastomosis. The basic principle of this procedure is similar to that of the biliopancreatic bypass, which promotes weight loss by producing selective malabsorption by limiting the food digestion and absorption to a short common ileal segment. The potential for metabolic complications still exist with this procedure; however, this potential is not as great as with BPB. Individuals undergoing the duodenal switch procedure require long-term medical follow-up and regular monitoring of fat soluble vitamins, vitamin B-12, iron and calcium. There is some disagreement among surgeons about how long to make the alimentary and common channels. In some series, the common channel was created to be 100 cm for all patients. In another series that obtained good results, the small bowel segments varied according to the original length of the bowel. In that series, the alimentary limb segment (excluding the common channel) is about 40% of the total length of the small bowel, with the common limb being about 10% of the length of the total original small bowel length in increments of 25 cm. The common limb, therefore, is usually 50 cm, 75 cm, or 100 cm long depending on the individual. The important consideration is to make the channels long enough to prevent malnutrition and short enough to result in effective EWL
And then they cite some of the literature:
Anthone GJ, Lord RVN, DeMeester TR, et al. The duodenal switch operation for the treatment of morbid obesity. Ann Surg. 2003; 238:618-628.
Deveney CW, MacCabee D, et al. Roux-en-Y divided gastric bypass results in the same weight loss as duodenal switch for morbid obesity. Am J Surg. 2004; 187(5):655-659.
Hess DS, Hess DW. Biliopancreatic diversion with duodenal switch. Obes Surg. 1998; 8(3):267-282.
Marceau P, Hould FD, Simrad S, et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998; 22:947-954.
Prachand VN, Davee RT, Alverdy JC. Duodenal switch provides superior weight loss in the superobese (BMI > or =50 kg/m2) compared with gastric bypass. Ann Surg. 2006; 244(4):611-619
I think I'd tell them that given the position of the Federal government and given the position of other insurance companies to include other BC companies and given the over ten years of peer-reviewed literature, that their calling the DS "experimental" makes as much sense as declaring hysterectomies experimental...and because of that, I'd want to hurry on through the appeal process so that it ca go to outside review.
And so on.
But really, really...you need help writing this from someone who is less emotionally involved and very detail-oriented and who enjoys a good fight. I think that trying to do this on your own would be a costly mistake. I wish I could volunteer, but I'm loaded on painkillers right now and trying to decided how close I am to needing cataract surgery...I just don't want to commit to something I can't follow through on.
Good luck,
Sue
Hockeymom87 · 0 replies · 604 views
