Question:
What is the difference in cost between the BPD/DS and RNY procedures?

I am currently battling with my insurance company and have Walter Lindstrom on the case (go, Walter, go!) regarding their denial of my PCP's referral to a nearby surgeon who does the duodenal switch procedure both lap and open. They have suggested two alternative surgeons who are both more than a 5-1/2-hour round-trip drive away and both of whom do NOT perform the BPD/DS procedure (which my PCP has recommended as being the most appropriate for me, and after my own extensive research I have to agree). Also, neither of them do their procedures laparascopically. In their denial, PacifiCare said that "the duodenal switch procedure does not meet PacifiCare's standards for safety and efficacy," even though I had provided them with a 10-page report that had been given to me by my PCP which compared the safety and efficacy of the DS to the RNY and VBG. Of course, I believe that the REAL issue for PacifiCare is what is ALWAYS is for ALL insurance companies: COST (read: MONEY). But, I have no idea what the difference in cost is between the RNY (which it appears they WILL cover) and the DS (which, at the moment, they won't). Can anybody give me a "ballpark" estimate of the difference in cost between the two procedures? I am hopeful that Mr. Lindstrom and I will prevail at the Independent Medical Review, and I will get to have the procedure that my PCP (and I) believe is most appropriate for me (BMI 61) and offers me the best chance for success. Thanks for any info on the cost comparison of these two procedures.    — Allison S. (posted on March 18, 2003)

March 18, 2003
Hi Allison. I cannot answer your question about the cost of either procedure, but I just had one comment to make. From my own extensive research of WLS, I have found that the majority of insurance companies do not cover DS surgery because they still consider it "experimental", the same goes for the Lapband as well. The DS and Lapband surgeries are gaining in popularity, so perhaps they will change their perception in time. <p> Incidentally, I had a BMI of 81 at the time of my Lap-RNY 2 months ago and at my 6 week checkup post-op, I had lost a total of 72 lbs!! My BMI is now 69 and my life is turning around quickly!! If you find that the fight with your insurance company will be a lengthy one, you may want to consider the RNY surgery so you can be losing now, instead of losing later. It is considered the "Gold standard" of WLS and the insurance companies pay for it more readily because it has been found SAFE and effective!! Good luck to you!!
   — thumpiez

March 18, 2003
If you go to www.lapsf.com, which is the website of Drs. Jossart, Cirangle and Feng in San Francisco, you will find buried in there somewhere the costs of both procedures, performed laparoscopically -- IT IS EXACTLY THE SAME!!! As I wrote here in answer to another question tonight regarding Aetna's "issues" with covering WLS at all, and in refusing to pay for the DS in particular:<P> Perhaps because "the powers that be" at Aetna find it morally troubling that the DS provides (for some, not for all) a more normal manner of eating after the weight is lost (or so I've heard) and doesn't punish the "gluttonous" who eat sugar by dumping (well, those of us without a serious sweet tooth don't NEED that -- I need my negative feedback [diarrhea and stinky poop] for eating greasy things!) -- perhaps they think the DS doesn't require enough long-term suffering and sacrifice? I don't know, I truly don't. The reasons on the Aetna Coverage Bulletin for MO Surgery is full of half-truths, ridiculous issues (they complain that the DGB/DS hasn't had "randomized clinical trials" -- but the cold scientific truth is (1) what patient in their right mind would agree to be randomly assigned to one of two major surgeries, each of which has different risks, different rationales, different recoveries, different long-term outcomes, different lifestyles required, different foods to eat, without knowing what it was going to be?; (2) because of the different recoveries, different long-term outcomes, different lifestyles required, different foods to eat, etc., THE PATIENT CANNOT BE BLINDED to what was done!; and (3) for the selfsame reasons, there never have been RCTs done for the RNY either, just longer (than the 18 years that DS has been done) times that data has been available because the surgery has been done for a longer time).<P> For a thousand reasons (as I'm sure Walter Lindstrom is telling you) there is absolutely no validity to the assertion that the DS is "experimental" -- Aetna even removed that assertion from their January 2003 revision to the WLS Coverage Bulletin, and now makes the totally vague assertion that it is "inadequately studied." It has a CPT code, doesn't it?? The AMA doesn't permit CPT codes for experimental procedures, to my knowledge. MANY surgeons are offering the procedure, and some have in good conscience STOPPED DOING THE RNY because the outcomes are clearly superior (OK, I'm not sure I agree that SOME people aren't better off with the RNY, e.g., those with a sweet tooth).<P> Don't get me started -- OOPS, TOO LATE! PLEASE let me know how your appeal goes! I'm off to write mine tomorrow after receiving the OK from Aetna -- but for the RNY, which was NOT what was requested! Diana
   — [Deactivated Member]