Question:
If Ins wants to pay for (example) RNY and I want a DS, am I stuck??

If my insurance considers a DS to still be "experimental" and I don't think I want the RNY, is there any reason the surgeon can't do the DS anyway and submit to insurance with fees for the RNY (which I understand are higher anyway - so it's not like he won't receive his fee)? I don't mean to sound unethical here, but. . . I don't want to come all this way only to be stopped by some Dr miles away sitting in an insurance office telling me what I can do with my own intestines! LOL!! Any ideas?? Thanks in advance!    — ChristiMNB (posted on March 12, 2001)

March 11, 2001
It is my understanding that there is someone in the surgery room who is in charge of writing down everything the surgeon does i.e. inscision or lap, procedure, time it took for each thing etc. so that they can bill the insurance with the correct and accurate procedure done. That's just what was explained to me by the Dr. office. It would be pretty hard to do a different procedure than what was approved and have the approved procedure show up on the billing when it wasn't the one done! Best of luck to you!
   — Karen S.

March 11, 2001
HI........ I decided that wanted the DS, and when I applied to my surgeon, he KNEW I wanted DS, but when he wrote to my insurance company, he accidentaly listed RNY as my surgery choice. Well, his office gal called me and said "congratulations! you are approved for the RNY procedure!" I said 'well, thanks, but I asked for the DS'.......she said 'oops.....let me see what's up with this.' She called back and said that the doc had made a mistake, which he owned up to, and that they would have to REAPPLY to my ins co! I was very apprehensive, I can tell you! It took 10 days, but I got the call that I had been approved for the DS! whew!!! Maybe you can reapply for the DS, and maybe you can use my doc.......Dr Dennis Smith in Marietta GA.............they pulled off some sort of magic and made it happen... good luck! jw
   — jane W.

March 12, 2001
That would be fraudulent and I would wonder if you would really find a Dr willing to be commit that knowing they risk losing their medical license.
   — [Anonymous]

March 12, 2001
I was in the same position and lost a fight with my former insurance company which was anHMO. However I switched to BC/BS federal and they paid for it/ I just want to encourage you to fight for the surgery you want. Many people win on appeal and it is worth the fight if you are sure the BPD/DS is for you. The other thought I had was that with the surgeon I used, there was no problem with getting approval. I don't know how they did it but they did it! The first surgeon I consulted didn't bother fighting insurance for me. GOod luck, I also recommend reading some of the posts on the egroups duodenal switch group since there are many filled with how they fought this particular denial for "experimental" surgery and won. We all know it isn 't experimental at all!
   — Jean S.

March 12, 2001
Actually, I think the fees for the DS are quite a bit higher than an RNY and the operation is more complex. However, this being said: I would talk with your surgeon about the insurance codes he/she uses. There is one for 'distal procedure' that I've heard *some* surgeons use to describe either a BPD/DS OR a distal RNY. It is not fraudulent because the code is very general and applies generally to a distal procedure. I wouldn't suggest going into a DS surgery with prior insurance approval for an RNY. I would definately discuss what codes are used by the surgeon and reapply for approval if you must. It is well worth it to get exactly the procedure you prefer and feel is right for you -- this is your new body and you will have to live with it for the rest of your life and make the accompanying lifestyle changes required. I wish you the best and hope everything goes well with the insurance! I had a laparoscopic BPD/DS on January 25, 2001 and haven't regretted it for a moment! :) all the best ([email protected]),
   — Teresa N.

March 17, 2001
You would need to make sure that your surgeon or PCP wrote a really detailed letter, outlining the things I've included below. To get what you really want, its better to be extremely specific during the approval process- include info such as: The Biliopancreatic Diversion with Duodenal Switch (BPD/DS) procedure is most effective for patients who are in the "super morbidly obese" range (BMI higher than 50), and provides the best chance at achieving a satisfactory percentage of excess weight loss (%EWL) for the patient. Dr. Douglas Hess of Bowling Green, Ohio, who initially devised the BPD/DS procedure in 1988, published a clinical study in 1998 (Hess, et al.: Biliopancreatic Diversion with a Duodenal Switch, Obesity Surgery, 8, 1998; 267-282.) concluding that the BPD/DS procedure achieves an average of 80%EWL, which occurs at 24 month post-operative and continues at a 70% level for eight years and beyond (By contrast, the Roux-en-Y procedure promises only 55%EWL.). In the case of those who are super morbidly obese, the BPD/DS procedure is warranted in order to give one the best chance to reach a healthy weight and to maintain the weight loss for the long-term. Other benefits of the BPD/DS procedure that are not found in the roux-en-y "pouch" procedure are as follows: 1.) Retention of the natural functionality of the reduced stomach.The partial gastrectomy leaves the pyloric valve intact and functioning, which means that there is no chance of post-operative problems that can plague RNY patients: blockages of the stoma, marginal ulcerations, narrowing of the anastomosis requiring endoscopic dilation, dumping syndrome. All of these problems can occur repeatedly in RNY patients; none of these problems can occur after the BPD/DS procedure. Furthermore, the BPD/DS stomach is left large enough that food can be properly digested before it is expelled into the small intestine. This means that BPD/DS patients may see greater protein absorption, and do see adequate production of intrinsic factor for vitamin B12 absorption, benefits that are not enjoyed by RNY patients. 2.) Retention of the duodenum in the food stream. Unlike other forms of gastric bypass, the BPD/DS procedure does not completely bypass the duodenum. The duodenum is where calcium,iron, protein and zinc absorption take place, so BPD/DS patients seldom experience dangerous deficiencies of these nutrients. By contrast, the RNY procedure completely bypasses the duodenum, which seems to compromise absorption of these nutrients to a greater degree. 3.) The BPD/DS's distal gastric bypass provides the best long-term weight loss potential, with little to no late regain of weight, as noted in the above-referenced Hess report. BPD/DS patients can reasonably expect to reach and maintain a healthy weight, whereas other forms of gastric bypass surgery see much greater failure rates and late regain of weight. Just a consideration.. I think that there is not nearly enough information about the DS on this website. I don't know why, but there just isn't. For more info, go to the duodenal switch information zone @ www.duodenalswitch.com. Good luck, no matter what you choose to do! - Liane French
   — Liane F.