Question:
Aetna Federal - RNY Revision to DS

I poked around the revision messageboard, but there is not a lot of information or activity there. I am an RNY patient about 4 1/2 years out. Started to have issues with food volume and feeling hungry. Doctor ordered an upper GI which indicated that the food is emptying out of my stomach very quickly. He states I am an excellent candidate for a revision and in fact he would like to make it a switch from RNY to "more like a DS". Aetna specifically states they will not pay for DS because it is considered "experimental". So my question is, I have federal Aetna insurance and was wondering if anyone out there has federal Aetna and if you've had any problems with getting revisions or DS surgeries approved?    — [Deactivated Member] (posted on February 16, 2006)

February 16, 2006
I didnt have Aetna "federal' but I did have Aenta. I had a non functioning pouch. The route my doctor took to fix it was the lapband ' also NOT paid for by Aenta at the time. Because this was for a 'fix' and NOT wls - they covered it. You might want to go that route and stress its to 'fix' something and not for WLS.
   — star .

February 16, 2006
Cannot have a r n y, or a band, non compatible with my Nissan wrap, for my gerd, no pouch to be used for arny, and a pouch would be negative for gerd with barrettes, and diabetes insipidus, which brings us to the second part of my bitch is that the federal gov provides the ds for congressmen but not the rest of us. congressman Jackson of illinois and Nader of NY had it at your expense. why not you. come to the ds forum. if that not where this is ,it show up in my mail box. as a new post item.
   — walter A.

February 16, 2006
Hiya. There are many options your surgeon and you can take. If revisions are covered, because the original WLS isn't working. (Like the lady said, have them state it's for a "fix", not for a new WLS.) He also doesn't have to call what he's doing a DS. He can call it a revision to a distal bypass. (Or something like that) These are just guesses, but please feel free to check out the DS message board (on this site), and the Yahoo DS group. (found at www.yahoogroups.com; do a search for "Biliopancreatic Diversion with Duodenal Switch) There are tons of very knowledgable (spelling?) DSers at those 2 places. Many, are revisions. =) Good luck to you! ~Amanda~
   — AmandaLeigh =)

February 16, 2006
There are a lot of people at my work who have had RNY. However we are only allowed one WLS in a lifetime. One lady was more than 3 years out and her opening from pouch to small intestine failed, and the food just went through her. She fought and lost many battles to get a revision and finally got her last denial. Just when she thought all hope was lost, and she was 5 lbs. heavier than when she had the surgery originally, she came across somebody on this site who told her about this Dr affiliated with Harvard Medical University. I'm sorry, but I don't remember his name. Anyway, this doctor can do a kind of revision by EGD. Basically he goes through the mouth and makes the repair that way. Less invasive. Also according to her, he will reform her pouch to the correct size. This IS covered by our insurance. Supposedly he's the only one who does this in this country. I wish I had his name. I'll have to ask her. She's going to see him in April. I hope this helps. Eleathia
   — Goshdarnpeople *

February 18, 2006
I got Aetna to pay for my DS, but they are bastards about it, and you will probably have to appeal all the way through their internal process, and then go to external medical review. The possibly good news is that the Federal Gov't external medical review agency is CHDR/Maximus, and they are VERY pro-DS and you have an excellent chance that they will overturn Aetna's denial. Find out what your external medical review route is and confirm this, and if it is true, then just hunker down for the pointless waste of time that appealing the Aetna denial internally will be, and try to get to external medical review as quickly as possible.
   — [Deactivated Member]