jcrowder

In mine we also talked about expectations for post-surgery life; family and friend support (or lack thereof), how I would cope with the required changes for the long term-what would be different this time; are my expectations for WL realistic, did I have an adequate understanding of the surgery, requirements, outcomes, etc.

I actually looked up my insurance company's guidelines for bariatric surgery/ obesity surgery online and read them so I didn't have to rely on the or my physician. You can also call but if you do ask them if they have their guidelines posted online and ask how to find them. Here are the guidelines for Aetna, as an FYI only http://www.aetna.com/cpb/medical/data/100_199/0157.html

I did the psych eval last which took about a week for her to do the report-- i went to a separate psychologist and then decided to continue counseling with her so when I saw her the next week I knew she'd submitted. Somehow in the process the doctors office didn't realize my 3 month window was up and didn't submit, so I put in a call. After that, it took about a week for approval. They initially said 2-3 weeks after all the paperwork is done and we hit the three month mark.

I did a shake diet previously for about a year. I haven't started my pre-op one yet, but am doing one shake a day working with a bariatrician while awaiting approval. I always made my shakes with a shake blender with ice + the water or it sounds like in your case the milk it called for. It increases the liquid volume (helps get in more water), usually leaves a little ice to chew on in the cup, and takes longer to drink. Someone in another post talked about "head hunger" versus actual hunger. That was the hardest to overcome in the first couple days. If you are done with your shakes or in between try blending up just ice and water to like a smoothie consistency and add lemon juice, sugar free/ calorie free drink mix or other sugar free type sweeteners to jazz it up a bit (if allowed). Go to bed early. Divert attention. The first few days are the worst for sure. I have trouble with lactose, so the whey based shakes are particularly hard on my stomach. Drink shake and not long after I am heading to the bathroom. If I recall from before, even folks who didn't have lactose issues went through a transition with their BMs when starting the all shake diet though. Best of luck!!

Hi Nickie- Belowis everything they identify as experimental or investigational per their policy bulletin. Here is the link to the original document: http://www.aetna.com/cpb/medical/data/100_199/0157.html It looks like band over bypass is on the list. My surgeon had suggested as one of three options to do an endoscopic suturing procedure. He said less risk, less cost, no hospital time but the results were also questionable and it had to be either/or. So if the endoscopic option didn't work, then I couldn't go back and do the laprascropic procedure later. Good news, I found out surgery was approved. Now I just need to decide whether to move forward or not. He was very keen on making sure I understand the increased risk and decreased opportunity for weight loss outcomes. Hence my full court press with counseling and weight loss meds as adjuncts. Let me know how yours turns out!!Experimental and Investigational Bariatric Surgical Procedures: AspireAssist aspiration therapy “Band over bypass” or LASGB revision of prior Roux-en-Y gastric bypass "Band over sleeve" or LASGB revision of prior sleeve gastrectomy Bariatric surgery as a treatment for idiopathic intracranial hypertension Bariatric surgery as a treatment for infertility Bariatric surgery as a treatment for type-2 diabetes in persons with a BMI less than 35 Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass as a treatment of gastro-esophageal reflux disease (GERD) Gastric bypass as a treatment for gastroparesis Gastroplasty, more commonly known as “stomach stapling” (see below for clarification from vertical band gastroplasty) Laparoscopic gastric plication (also known as laparoscopic greater curvature plication [LGCP]), with or without gastric banding LASGB, RYGB, and BPD/DS procedures not meeting the medical necessity criteria above Liposuction (suction-assisted lipectomy; ultrasonic assisted liposuction) Loop gastric bypass Mini gastric bypass Natural orifice transoral endoscopic surgery (NOTES) techniques for bariatric surgery including, but may not be limited to, the following: Gastrointestinal liners (endoscopic duodenal-jejunal bypass, endoscopic gastrointestinal bypass devices; e.g., EndoBarrier and the ValenTx Endo Bypass System); or Intragastric balloon (e.g., the ReShape Integrated Dual Balloon System); or Restorative obesity surgery, endoluminal (ROSE) procedure for the treatment of weight regain after gastric bypass surgery; or Transoral gastroplasty (TG) (vertical sutured gastroplasty; endoluminal vertical gastroplasty; endoscopic sleeve gastroplasty); or Use of any endoscopic closure device (Over the Scope clip [OTSC] system set, Apollo OverStitch endoscopic suturing system, StomaphyX endoluminal fastener and delivery system) in conjunction with NOTES; Open adjustable gastric banding Prophylactic mesh placement for prevention of incisional hernia after open bariatric surgery Roux-en-Y gastric bypass as a treatment for gastroesophageal reflux in non-obese persons Sclerotherapy for the treatment of dilated gastrojejunostomy following bariatric surgery Silastic ring vertical gastric bypass (Fobi pouch) Vagus nerve blocking (e.g., the VBLOC device, also known as the Maestro Implant or the Maestro Rechargeable System) VBG, except in limited circumstances noted above.

I'm still in the pre-cert process, finished my 3 month waiting period. But for a revision for a RNY done 25 years ago. I've tried and failed even with the surgery so for me really needed to do something more than just going it on my own. I did my psych eval with a licensed therapist who was in network for my insurance provider who specializes in eating disorders-- the gamut, not just for folks who are overweight. I decided to continue therapy with her-- to address eating disorder issues and what I believe to be some mild depression (most likely tied to the weight, maybe). I've never gone to counseling or therapy before besides the stuff you might get with weight loss programs. We've been meeting weekly thus far. No magic bullets, still feel like we're in the getting to know you phase. She eventually suggested meeting with a bariatrician in the health system who prescribes weight loss medications, she felt like they would be a useful adjunct to my effort to try to lose weight (and keep it off if I get there) whether my surgery is approved or not. I did that and just started those this week. The bariatrician had a list of meds and we talked through the mechanism of action and which might be the best for my eating triggers/issues, she also provided a list of dietary changes, exercise plan, etc. I'll continue to meet with her for tracking. She said average/best loss with meds is 10% so doesn't get me close to where I want, but could help. She has a lot of patients who had WLS who she follows and use meds-- some til they get to goal weigh and some who have stayed on them longer term. ALL of that say I encourage you to continue exploring those other avenues and perhaps consider what other formal supports you might be able to identify (licensed counseling, support groups for accountability, etc.) that you haven't yet tried to help you be as successful as you can.

If you are truly hungry (not head hungry) is there a reason you couldn't add in one more shake? Are you tracking calories? If not you should consider. If your one meal a day ends up blowing it out of the water because you're starving yourself on the shakes you'll end up sabotaged. FYI- When I make my shakes I add in extra ice and leave it a little crunchy. Something to chew during the day definitely helps with that need.

So your post sounds just like me...add a few advanced nursing degrees AND the fact that I had RNY done 25 years ago to make me feel like even more of a failure. I'm back going through the process of considering a revision to my original surgery at my highest weight ever. IF insurance will approve. While it would be awesome to get a total do-over with the RNY process (not just the reducing the stomach which is essentially what I'm not a candidate for) I don't regret my decision 25 years ago. I am sad that back then there was little/no follow-up, no real rules on diet/caffeine/timing of water intake/etc --maybe I'd have had better long term success. BUT I did lose just over 100lbs. Felt better than I had in my entire life and did more than I'd ever done - travel, marriage, shoppig in normal size clothing stores, etc. I have been morbidly obese since 6th grade and overweight since I was 7. That surgery got me closer to "normal" than ever. No diet I did before that or since then has been so successful- a year long protein shake diet did result in 70lbs lost but then I regained all + some much faster than after surgery. But, I realize now that I half-assed the process and expected that it would just magically work on its own. I'm sure deep down I probably still sort of think that way. I'm older have a couple kids that wish mom was more active and am restricted from doing things because of my weight and that makes me sad. This time I'm throwing everything at it...sort of feel like it's my last ditch effort. After my mandated psych eval for surgery I opted to continue working with the counselor who specializes in all types of eating disorders and am seeing a bariatrician who will prescribe WL meds. I've long thought until someone fixes the chemicals in my brain WL will never be long term, so I believe in meds. I'm taking the process so slow unlike in the past where I jumped into huge lifestyle shifts that were only sustainable for short-ish periods of time. I didn't even start a legit "diet" until just this week even though I've been going through the pre-cert process since October...and it's not really a diet- just replacing one meal a day with a shake per the changes prescribed by the bariatrician. On the advice of the counselor I've been setting one really small goal each week that is hopefully attainable and I'm able to maintain. Who knows what will happen with the WLS approval process. I'm hopeful the other adjuncts I'm working on will help me be successful for the long term. IF surgery is approved, it's really just another piece of the WL puzzle though a really nice one in terms of the ability to lose weight rapidly. It's up to me to keep it off though.

I don't have tons to offer on the recert process, but am sort of in a similar place. I have Aetna PPO. Had RNY in 1992 (gulp) dropped 100#s, regained most and tried to have a revision 8 years after initial and went through ALL the hoops only for insurance to deny saying I didn't have any comorbidities. I'm hoping that was a LONG time go and things have changed since. I went to surgeon in October (had to view online webinar or go to in person session first). Even for a revision the nurse who does pre-certs said Aetna would require me to do the 3 month diet/multi disciplinary approach. Had to meet with dietitian x 3 1 1:1 sesssion and 2 group sessions-- the group sessions were pretty lame), exercise specialist (not super helpful), get a pysch eval and met with physician a couple times. I had an EGD and upper GI done. Upper GI showed my stomach was near normal capacity, stoma stretched out and small intestines enlarged-- I didn't need the test to tell me that I can tell by the quantity of food I can eat. My insurance actually covered all the pre-op visits with no co-pay except for the psych eval. If I went through their office it was going to be $300 cash. I asked about using a provider in my plan, they made a suggestion and I did my psych eval with her for my regular behavioral health co-pay. She is a eating disorder specialist (all kinds) and I actually opted to end up continuing sessions with her for the time being. It's covered as part of my behavioral health benefit. If I can't figure out what is driving me to eat so much and eat through my surgery having another won't do much good for the long term. I had everything done as of the end of January. The office could have submitted as of Jan 20th but I guess forgot and I didn't think to call to remind. I was in yesterday meeting with their bariatrician and asked and they said they would submit for pre-cert right away. It takes 2-3 weeks. The gal in the office said she's 80-85% sure it will be approved. Since I went through all this years ago and was rejected I'm super anxious. I read through my insurer's coverage documentation for WLS before going to see the doctor. One of the options he recommended is not covered by my insurer because they consider it experimental-- even though it is the least expensive and least invasive. So that is off the table. He said revisions can have A LOT of complications, so I need to think long and hard about revision surgery. If it's approved...I'm going for it. In addition to continuing with seeing the counselor I also opted to see the bariatrician they have in their medical group (they are affiliated / part of the large health system in our area) just yesterday. I figured if surgery isn't approved, I need a plan B and even if it is I need as much concerted effort/focus on trying to make this work as possible. The counselor has suggested medication with or without surgery as an adjunct after our third session based on my eating patterns/habits. The bariatrician prescribed Qsymia which I started today (I'd already had a batter of labs, tests, etc. so knew I was healthy enough to start). She said she has a lot of WLS patients who use medications in addition to or after surgery once they plateau or if they start to regain. She listed out all the med options and I chose this one in particular. It was also the one she said her patients have the best results and least side effects with. She also had me start a food diary and replacing one meal per day with protein shake and gave me an exercise plan-- so not just the script for meds. My insurance won't cover but got a manufacturer's card to help reduce the price. I did find in their coverage determination documentation IF I had tried to lose with for months and was not successful then they would have covered. I don't want to wait around... She said the variety of medications provide a nice arsenal of adjunct support and she has moved patients between different medications if they build up a tolerance. In the past I've responded really well to phentermine and this has that in it, so I'm hopeful. Before hooking up with the bariatric group at the health system I couldn't find a counselor who specialized in eating disorders for adults who are overweight and finding a physician to prescribe the newer WL meds was impossible (I tried both independently). SO, if nothing else, the process has helped me connect with those resources. While I do feel a little like they "herd" patients through the process in some ways (group dietitian visits that weren't super great) they really seem to know how to manage the process. I know I overshared-- more than what you asked about-- but thought some of this might be of use since we are in a similar spot having regained after our first surgery. Curious to hear from anyone else AND how your process shakes out. Best of luck to you! Jolie