Desperately need revision to DS
Hello,
I haven't been posting on the boards for quite a while, but have been around for the past 8 years or so. I had gastric bypass 8 years ago, lost over 200 pounds, then after 3-4 years, started gaining back. Now, not only have I regained most all the weight back, but am having severe mobility problems and in worse shape now than I was when I had gastric bypass.
For over a year now, I have been trying to get insurance approval for a revision to the DS surgery. I have contacted Dr. Husted and he has evaluated my records and determined that my gastric bypass surgery failed me metabolically. Prior to this, I felt nothing but dispair and a sense of failure.
When I first started researching weight loss surgeries, I wanted to have a DS and use Dr. Husted then. I actually had an appointment with him to attend a seminar, then found out that my insurance didn't cover out-of-state physicians. So, I found a surgeon in my state (AL). Now, my surgeon was good, but he wasn't a bariatric surgeon and he wasn't there to help determine what the BEST SURGERY FOR ME was. Since that time, I have learned how important it is for us to research every type of surgery thoroughly and if your surgeon doesn't help in determining that, then it is up to us. There are so many things to consider and so important that we look at everything.
This brings me to the present. After all my ups and downs, I finally felt I had found the answer. After talking with Dr. Husted, I knew that the DS surgery was the still the right choice for me. I began the insurance process, and if I thought I had had problems before, I didn't realize how many problems were to come. I have been denied 3 times from the insurance (Blue Cross Blue Shield of AL). I hired a bariatric appeals specialist and she started handling my appeal in January of 2009. After reviewing my contract, she felt that my revision surgery should be covered, and stated that she wouldn't have taken my case if she didn't think she would win. We have currently went through several appeal processes and involved the company through which we have insurance. She now feels that we may be facing an external review. The only good thing about this is that I can send in additional documentation. She has suggested that perhaps a 3rd opinion would be helpful.
I need to find a doctor who does revisions to the DS from gastric bypass. I have several names but was wondering if anyone here could recommend someone? I don't mind traveling but hope that I can stay in the southern area.
If anyone has any information regarding the surgeons or anything on insurance appeals, I would certaintly love to hear from you. I have done nothing but jump through hoops and it can get very discouraging.
Thanks so much
Cherie
I haven't been posting on the boards for quite a while, but have been around for the past 8 years or so. I had gastric bypass 8 years ago, lost over 200 pounds, then after 3-4 years, started gaining back. Now, not only have I regained most all the weight back, but am having severe mobility problems and in worse shape now than I was when I had gastric bypass.
For over a year now, I have been trying to get insurance approval for a revision to the DS surgery. I have contacted Dr. Husted and he has evaluated my records and determined that my gastric bypass surgery failed me metabolically. Prior to this, I felt nothing but dispair and a sense of failure.
When I first started researching weight loss surgeries, I wanted to have a DS and use Dr. Husted then. I actually had an appointment with him to attend a seminar, then found out that my insurance didn't cover out-of-state physicians. So, I found a surgeon in my state (AL). Now, my surgeon was good, but he wasn't a bariatric surgeon and he wasn't there to help determine what the BEST SURGERY FOR ME was. Since that time, I have learned how important it is for us to research every type of surgery thoroughly and if your surgeon doesn't help in determining that, then it is up to us. There are so many things to consider and so important that we look at everything.
This brings me to the present. After all my ups and downs, I finally felt I had found the answer. After talking with Dr. Husted, I knew that the DS surgery was the still the right choice for me. I began the insurance process, and if I thought I had had problems before, I didn't realize how many problems were to come. I have been denied 3 times from the insurance (Blue Cross Blue Shield of AL). I hired a bariatric appeals specialist and she started handling my appeal in January of 2009. After reviewing my contract, she felt that my revision surgery should be covered, and stated that she wouldn't have taken my case if she didn't think she would win. We have currently went through several appeal processes and involved the company through which we have insurance. She now feels that we may be facing an external review. The only good thing about this is that I can send in additional documentation. She has suggested that perhaps a 3rd opinion would be helpful.
I need to find a doctor who does revisions to the DS from gastric bypass. I have several names but was wondering if anyone here could recommend someone? I don't mind traveling but hope that I can stay in the southern area.
If anyone has any information regarding the surgeons or anything on insurance appeals, I would certaintly love to hear from you. I have done nothing but jump through hoops and it can get very discouraging.
Thanks so much
Cherie
Cherie,
You should also post this over on the DS messageboard. There are LOTS and LOTS of experienced people who have not only insurance/legal backgrounds.... but... people who have been denied & appealed & WON!!!!!
http://www.obesityhelp.com/forums/ds/a,messageboard/
And here are some other helpful links for you.....
http://www.duodenalswitch.com/
www.dsfacts.com
Don't lose hope!!!!!
-Jamie
You should also post this over on the DS messageboard. There are LOTS and LOTS of experienced people who have not only insurance/legal backgrounds.... but... people who have been denied & appealed & WON!!!!!
http://www.obesityhelp.com/forums/ds/a,messageboard/
And here are some other helpful links for you.....
http://www.duodenalswitch.com/
www.dsfacts.com
Don't lose hope!!!!!
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Wow Cherie.
Good Luck.
Go to the DS forum. They certainly have information with appeals & RNY to DS revision surgeons.
It sounds like you need to do something IMMEDIATELY proactive with your diet in the meanwhile. You need to be in the best health they you can be in to undergo such a major surgery. You need to give yourself the best possible chance.
Best,
Leila
Good Luck.
Go to the DS forum. They certainly have information with appeals & RNY to DS revision surgeons.
It sounds like you need to do something IMMEDIATELY proactive with your diet in the meanwhile. You need to be in the best health they you can be in to undergo such a major surgery. You need to give yourself the best possible chance.
Best,
Leila
3/30/2005 Lap Band installed 12/20/2010 Lap Band REMOVED
6/6/2011 Vertical SLEEVE Gastrectomy
I am going through something similar trying to get an approval for a revision from an RNY to DS. I was denied my first time, then my first appeal, and now I'm on the second appeal. How is your policy worded as far as their criteria for revisions?
Apparently, for my policy, a person has to have a "mechanical failure" with their original surgery. (ie: obstructions, stricture, staple line failure, pouch dilation due to vomiting) and they really get people with the whole "due to vomiting" part.
I have a stretched pouch and stretched stoma (as shown on 2 endoscopes), have had a couple staples actually come undone (but that's not "enough" to be considered a staple-line failure), and numerous records of being treated for nausea/vomiting----and my only theory for being denied so many times is perhaps they actually need it spelled out for them in the "letter of medical necessity" that the surgeon of your choice writes for you.
Obviously there is no "test" to prove that any pouch is stretched exclusively due to vomiting (unless we're expected to have went to the ER as we were nauseas, and were able to vomit *just in time* to have it shown on an upper GI, EACH time we've thrown up since our original surgery...and have the x-ray techs measure the pouch every time and keep a record of it's "growth") but that's totally ridiculous, non-realistic, and I guess we have to pretty much find a revision surgeon who will take our word.
Have they said why they deny it each time, or can you only get a "it's not medically necessary" from them when you ask?
*edit* btw, I have bcbs, too.
Apparently, for my policy, a person has to have a "mechanical failure" with their original surgery. (ie: obstructions, stricture, staple line failure, pouch dilation due to vomiting) and they really get people with the whole "due to vomiting" part.
I have a stretched pouch and stretched stoma (as shown on 2 endoscopes), have had a couple staples actually come undone (but that's not "enough" to be considered a staple-line failure), and numerous records of being treated for nausea/vomiting----and my only theory for being denied so many times is perhaps they actually need it spelled out for them in the "letter of medical necessity" that the surgeon of your choice writes for you.
Obviously there is no "test" to prove that any pouch is stretched exclusively due to vomiting (unless we're expected to have went to the ER as we were nauseas, and were able to vomit *just in time* to have it shown on an upper GI, EACH time we've thrown up since our original surgery...and have the x-ray techs measure the pouch every time and keep a record of it's "growth") but that's totally ridiculous, non-realistic, and I guess we have to pretty much find a revision surgeon who will take our word.
Have they said why they deny it each time, or can you only get a "it's not medically necessary" from them when you ask?
*edit* btw, I have bcbs, too.
I'm sorry to hear of the problems you've had with trying to get your approval for your revision. I'm not sure what state you're from but bcbs in AL can really be a headache. My situation is a bit different. When I went back to the surgeon who did my gastric bypass about 3 years ago he wrote in my records that I was non-compliant. Shortly after this, I began to research having revision surgery and my search led me to Dr. Husted and the DS surgery.
Dr. Husted wrote a letter to my insurance company stating that my gastric bypass surgery had failed me because of metabolic reasons. I always felt that there was something not right and the DS surgery was what I should have went with from the beginning.
So, as a result, the insurance company has denied me basically because of this statement. As far as what you asked about how my policy was written concerning revisions - I'm not sure about that. My appeals specialist read it thoroughly and she is convinced that my revision surgery should be covered however. Sorry I couldn't be of further help on that issue. But hang in there - maybe we'll both get our revisions!
Dr. Husted wrote a letter to my insurance company stating that my gastric bypass surgery had failed me because of metabolic reasons. I always felt that there was something not right and the DS surgery was what I should have went with from the beginning.
So, as a result, the insurance company has denied me basically because of this statement. As far as what you asked about how my policy was written concerning revisions - I'm not sure about that. My appeals specialist read it thoroughly and she is convinced that my revision surgery should be covered however. Sorry I couldn't be of further help on that issue. But hang in there - maybe we'll both get our revisions!
Cherie
Yeah, from my understanding, most of us in need of a revision have at one point lost a good amount of weight, and no matter the pouch size (whether it is messed u*****t) a lot of the regain/body's resistance to lose any more excess weight, has to do with metabolic failure or whatever. (I've talked to Husted and read posts from other DS surgeons regarding that)
I'm assuming it's a common thing (metabolism issues) that insurance companies have yet to "accept"...kind of like the stretched stoma is.
There's no telling what my "original surgeon" has wrote about me in my chart, LoL. I was concerned with the "amount I was able to eat" from the beginning, but my surgeon never was. I lost weight for 10 months, then it stopped. He moved to a different state, though. So, I have records from other surgeons I've followed up with since he left a few yrs ago. He was kind of one of those surgeons who was quick to blame failure on a patient, without having any "proof" to back it. (in other words, he wasn't one to do any kind of tests to check the pouch..lol)
What statement is causing you the trouble? The "metabolic" one, or the "non-compliant" one? I can see where bcbs would immediately "deny" any case that involves either of those problems. They seem to be way more "selective" than they were when I had my first surgery. Are you having to pay for the person helping you w/ your appeals, or was it someone who was "assigned" to you? I remember always having a certain person who worked on my cases in the past (I had an RNY, Tummy Tuck (Lol, it looks awful now), and a breast reduction - and all of those times it seems like I had someone who helped me out. It seems that I've been "on my own" as far as the revision has been concerned.)
I'm assuming it's a common thing (metabolism issues) that insurance companies have yet to "accept"...kind of like the stretched stoma is.
There's no telling what my "original surgeon" has wrote about me in my chart, LoL. I was concerned with the "amount I was able to eat" from the beginning, but my surgeon never was. I lost weight for 10 months, then it stopped. He moved to a different state, though. So, I have records from other surgeons I've followed up with since he left a few yrs ago. He was kind of one of those surgeons who was quick to blame failure on a patient, without having any "proof" to back it. (in other words, he wasn't one to do any kind of tests to check the pouch..lol)
What statement is causing you the trouble? The "metabolic" one, or the "non-compliant" one? I can see where bcbs would immediately "deny" any case that involves either of those problems. They seem to be way more "selective" than they were when I had my first surgery. Are you having to pay for the person helping you w/ your appeals, or was it someone who was "assigned" to you? I remember always having a certain person who worked on my cases in the past (I had an RNY, Tummy Tuck (Lol, it looks awful now), and a breast reduction - and all of those times it seems like I had someone who helped me out. It seems that I've been "on my own" as far as the revision has been concerned.)
Seems like we have some common issues here with trying to get our revision surgery approved. Some days I get very discouraged and think it will never happen, but all we can do is hang in there and keep trying - giving up would be easy, but if we do, thats it.
The statement that is giving me the most trouble is the non-compliant one. Even the company through which we have insurance is sticking with it and so far, hasn't considered the other documentation I have from Dr. Husted. My appeals specialist insists that I am not getting a full and fair review. She is from GA and I found out about her through someone on the DS message board. They had used her and gotten approval for their DS surgery (not revision). So, I contacted her, told her my story and sent her my contract. After reading it, she told me that my revision should be covered according to how it read. Yes, she charges, but it was only 95.00. I fully believe that she knows her stuff, is very knowledgeable and if she believes that you are entitled to your surgery and your contract should cover it, she will fight for it. If you are interested in talking with her, I'd be glad to give you her name and number. Just email me personally (I've put my address at the bottom). I don't think I could have went this far on my own.
You mentioned you had talked with Dr. Husted - do you have a surgeon you plan on using for your revision? Also, I was wondering where you are from and where you had your first surgery?
Have a great day!
Cherie
([email protected])
The statement that is giving me the most trouble is the non-compliant one. Even the company through which we have insurance is sticking with it and so far, hasn't considered the other documentation I have from Dr. Husted. My appeals specialist insists that I am not getting a full and fair review. She is from GA and I found out about her through someone on the DS message board. They had used her and gotten approval for their DS surgery (not revision). So, I contacted her, told her my story and sent her my contract. After reading it, she told me that my revision should be covered according to how it read. Yes, she charges, but it was only 95.00. I fully believe that she knows her stuff, is very knowledgeable and if she believes that you are entitled to your surgery and your contract should cover it, she will fight for it. If you are interested in talking with her, I'd be glad to give you her name and number. Just email me personally (I've put my address at the bottom). I don't think I could have went this far on my own.
You mentioned you had talked with Dr. Husted - do you have a surgeon you plan on using for your revision? Also, I was wondering where you are from and where you had your first surgery?
Have a great day!
Cherie
([email protected])
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