gviscio

go to another one just to get a follow up. they sometimes let you slide. they really want to see that you made an effort.

Use this in your appeals and also request for surgery JAMA -- Abstract: Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes: A Randomized Controlled Trial, January 23, 2008, Dixon et al. 299 (3): 316 Adjustable Gastric Banding and Conventional Therapy for Type 2 DiabetesA Randomized Controlled Trial John B. Dixon, MBBS, PhD; Paul E. O’Brien, MD; Julie Playfair, RN; Leon Chapman, MBBS; Linda M. Schachter, MBBS, PhD; Stewart Skinner, MBBS, PhD; Joseph Proietto, MBBS, PhD; Michael Bailey, PhD, MSc(stats); Margaret Anderson, BHealthMan JAMA. 2008;299(3):316-323. Context Observational studies suggest that surgically induced loss of weight may be effective therapy for type 2 diabetes. Objective To determine if surgically induced weight loss results in better glycemic control and less need for diabetes medications than conventional approaches to weight loss and diabetes control. Design, Setting, and Participants Unblinded randomized controlled trial conducted from December 2002 through December 2006 at the University Obesity Research Center in Australia, with general community recruitment to established treatment programs. Participants were 60 obese patients (BMI >30 and <40) with recently diagnosed (<2 years) type 2 diabetes. Interventions Conventional diabetes therapy with a focus on weight loss by lifestyle change vs laparoscopic adjustable gastric banding with conventional diabetes care. Main Outcome Measures Remission of type 2 diabetes (fasting glucose level <126 mg/dL [7.0 mmol/L] and glycated hemoglobin [HbA1c] value <6.2% while taking no glycemic therapy). Secondary measures included weight and components of the metabolic syndrome. Analysis was by intention-to-treat. Results Of the 60 patients enrolled, 55 (92%) completed the 2-year follow-up. Remission of type 2 diabetes was achieved by 22 (73%) in the surgical group and 4 (13%) in the conventional-therapy group. Relative risk of remission for the surgical group was 5.5 (95% confidence interval, 2.2-14.0). Surgical and conventional-therapy groups lost a mean (SD) of 20.7% (8.6%) and 1.7% (5.2%) of weight, respectively, at 2 years (P < .001). Remission of type 2 diabetes was related to weight loss (R2 = 0.46, P < .001) and lower baseline HbA1c levels (combined R2 = 0.52, P < .001). There were no serious complications in either group. Conclusions Participants randomized to surgical therapy were more likely to achieve remission of type 2 diabetes through greater weight loss. These results need to be confirmed in a larger, more diverse population and have long-term efficacy assessed. Trial Registration actr.org Identifier: ACTRN012605000159651 Author Affiliations: Centre for Obesity Research and Education (Drs Dixon, O’Brien, Chapman, Schachter, and Skinner and Mss Playfair and Anderson) and Department of Epidemiology and Preventive Medicine (Dr Bailey), Monash University, Melbourne, Australia; and Department of Medicine (AH/NH), University of Melbourne, Melbourne (Dr Proietto).

Viscio Law and The Obesity Law Center - Documents and Research That is the link to the NIH Criteria. It is over 40 with no co-morbs and 35 and over with one co-morb and NOT a significant co-morb like they say sometimes,when they'll ask for some deadly disease. Arthritis or depression can count as well. Gary

CIGNA may face murder charges over this one Family sues insurer who denied teen transplant - Health care - MSNBC.com MAybe it will hep us all out along the way if they finally look at how these companies look at patients, and make medical decisions. Gary

They're trying to scare you away.

They are supposed to, but I hear different stories on fills. Check out armytimes.com there's a section in there someplace on insurance. I'll try to find it and post the link

I'm sorry it should say WEIGHT LOSS SURGERY, not gastric bypass they actually called it "other radical surgeries" which is very annoying, but the study is pro for us. Finally. Sorry, it I couldn't edit the post

CNN REPORTS THE MOST COMPREHENSIVE PROOF THAT Gastric Bypass Lowers Risk of Death TIME MAGAZINE AUGUST 22, 2007 By Sora Song Whether one regards bariatric surgery — last-resort weight-loss operations such as gastric bypass and stomach stapling — as an essential treatment for obesity or as a failure of the fat person's will, the fact is, it works. Studies have shown that after surgery, patients often lose 50% or more of their excess weight — and keep it off — and symptoms of obesity-related conditions like diabetes, high blood pressure, high cholesterol and sleep apnea are improved or eliminated altogether. Now, two new studies in the New England Journal of Medicine (NEJM) show another long-term benefit: a lower risk of death. The larger of the two studies — the largest of its kind — led by researchers at the University of Utah School of Medicine, looked specifically at gastric bypass surgery, also known as Roux-en-Y gastric bypass, which accounts for 80% of all bariatric surgeries in the U.S. The operation involves creating a small walnut-size pouch at the top of the stomach, which is then stapled off and connected to the small intestine lower down than usual; the result is that patients can eat only an ounce of food at a time, and the food bypasses most of the stomach and the top part of the intestine, limiting the number of calories the body absorbs. In the Utah study, researchers compiled data on 15,850 severely obese people, half of whom had undergone gastric bypass surgery between 1984 and 2002, and half who were from the general population and had had no surgical intervention for obesity. Overall, researchers found, the surgery patients were 40% less likely to die from any cause during a mean 7 years of follow-up, compared with the obese controls. What's more, the mortality rate attributable to obesity-related disease was 52% lower on the whole in the surgery group: after gastric bypass, patients were 92% less likely to die from diabetes, 59% less likely to die from coronary artery disease, and 60% less likely to be killed by cancer. Results like these have got some doctors intrigued enough to start thinking about bariatric surgery as a treatment for conditions other than obesity —especially diabetes. A growing body of research suggests that the surgery may reverse the disease, a potential solution that could help some 20 million American diabetics. Though the current NEJM study did not specifically study the impact of bariatric surgery on diabetes, it did reveal a 92% reduced risk of death from the disease in surgery patients —findings that support what has been emerging in other experiments. "In more than 80% of patients who are severely obese and have diabetes and then have gastric bypass surgery, the diabetes is cured," says Ted Adams, professor of cardiovascular genetics at the University of Utah School of Medicine and lead author of the new study. "The interesting thing is that the resolution of diabetes happens within a few weeks following surgery, long before patients have lost their weight." Like some other researchers in the field, Adams believes that the surgery triggers other biological mechanisms, separate from weight loss — perhaps an interruption of a crucial biochemical pathway or a change in the release of certain hormones in the stomach or small intestine — that may have powerful effects on diabetes. "The gastric-bypass patient is really providing a source of intriguing research related to all kinds of disease treatment as well as weight gain and weight loss," says Adams. The second study, led by researchers at Gothenburg University in Sweden, involved 4,047 obese volunteers, 2,010 who underwent some form of bariatric surgery and 2,037 who received conventional obesity treatment, including lifestyle intervention, behavior modification or no treatment at all. Ten years after surgery, researchers report, the bariatric surgery patients had lost more weight and had a 24% lower risk of death than the comparison group. Though the overall number of subjects in this study is much smaller than the first, the results confirm general benefits of bariatric surgery, and gastric bypass in particular: after 10 years, bypass patients had maintained a 25% weight loss, compared to a 16% loss in patients who had stomach stapling, and 14% in those who underwent a banding procedure. In both studies, surgery patients had an overall lowered risk of death, but an interesting finding in the Utah study shows that these patients were 58% more likely to die from other causes, such as suicide and accidents. The authors speculate that as people lose weight and become more active, they also become more prone to accidents, which may up their risk of death. Surgery patients may also have pre-existing psychological problems — a history of abuse, perhaps — that can't be resolved by losing weight. "There have been some studies reporting that following bariatric surgery, some individuals may be more prone to chemical dependency, such as increased alcohol use," says Adams. "There's some speculation that certain addictive behaviors that are in place before the surgery — with food, for example — are transferred to alcohol or another addictive behavior." "Hopefully this research will stimulate additional evaluation of what the optimal approach is for evaluating candidates for this surgery," says Adams. "I think we should never lose track of the importance of individual evaluation of benefits and risks." Last year, an estimated 177,600 patients underwent bariatric surgery, a figure that's likely to grow as Americans get fatter and fatter. Though modern surgery techniques have become more sophisticated, less invasive and safer than in the past, the bariatric procedure still carries all the risks of any other operation. Patients have a .5% to 1% chance of death. The risk of gallstones goes up. Sometimes a second surgery is necessary. And all patients must be careful to make up for Vitamin and mineral deficiencies. The surgery isn't for everyone; current guidelines recommend it as a last resort, only for the morbidly obese who have a BMI of 40 and higher, or for the obese with a BMI of 35 and higher plus a serious weight-related illness like diabetes or hypertension. This should help. Gary Viscio Viscio Law and The Obesity Law Center - Welcome

BCBS of IL will pay when pressed They want you to feel defeated ashamed and embarrassed DONT

I've been getting flooded with questions on revisions. So, here's a short article I wrote for OAC, hope it helps. The weight loss surgery field has experienced exponential growth over the past four years. As a result, I find myself being asked more and more questions regarding post operative surgery. Be it plastic surgery, or a revision, the sheer numbers of post op patients is increasing the demand for these two types of post op procedures. In this article, we’ll talk solely about revisions. And that word, revision, gives rise to a number of included terms such as failed surgery, non compliance and revision to a new procedure. Revision, defined, is to change or modify. For our purposes, to change or modify a prior bariatric surgery. There are several areas where revisions can arise. A patient will be dealing with either a revision of a failed bariatric procedure, or a revision to a new type of procedure not approved or even in existence at the time of the original surgery. In either case the question is the same. Will my insurance carrier cover a revision? Simple question, but a not so simple response. As we all know insurance companies seem to make decisions by throwing darts at a dartboard. So it’s only natural to assume that a carrier will have different responses for different individuals from different states. To begin, a request for a revision based upon a failed prior bariatric surgery is going to immediately invoke a response from most insurance carriers questioning whether the prior surgery actually failed, or the patient was simply not compliant with the requirements of the first surgery. In other words eating past the pouch or band. A revision from a prior procedure to a new type of procedure is going to receive similar questions along with the additional question of why the patient is seeking to change from a RNY to LAPBAND or DS. Before you make this type of request it is imperative that you and your surgeon are on the same page. He or She should be aware of the exact need for the surgery, as well as your compliance issues during the original procedure. Never wait for the insurance company to ask the question. Answer it when your surgeon submits the request for authorization. If the your going the pouch has stretched, staple line failed, band slipped or bypass simply hasn’t worked you must have the pre-op testing to prove these allegations. Whether an MRI, CT Scan or Endoscopy you should have the results before you apply for certification. Likewise, you should provide your surgeon with a general description of your compliance over the years, consisting of a diet and exercise history. Chances are your BMI has been low while at times and you no longer have any significant co-morbidities. In this case your going to make sure that the carrier knows that if the revision is not granted, it will only be a short matter of time before your BMI climbs even higher and your co-morbidities return. If your request involves a new type of surgery, perhaps one that didn’t exist when you had your original surgery, make sure the reasons why this surgery is right for you are included in the request for surgery. These pre-emptive strikes just may get you the approval you seek by answering the insurance company’s questions before they’re asked. I know what you’re thinking. Supposed my insurance company does not or no longer covers bariatric or weight loss surgery. Well, in that situation you’re going to argue two things. First, that weight loss surgery should be a covered expense because it is used to treat co-morbidities in addition to obesity, such as diabetes or hypertension. And second, that this is a request to correct a failed procedure that may cause significant problems in the near future and as such it is not for obesity or weight loss. A tougher argument but one that has been made successfully. So remember, like your request for your original surgery, you must document your claims. And, of course, never quit. Gary Viscio Viscio Law and The Obesity Law Center - Welcome RNY 7/1/03 -166lbs

hard to say state by state. i deal more with BCBS and CIGNA if that helps.GHI and aetna usually cover the band

There's a new band coming out. Ethicon purchased a swiss company that made a swiss band. It is supposed to be out in the next few months. What does it mean. Just that you'll have more choices. (as long as insurance covers the new band with no problems) I'll try to find a link Gary

let me know if you want anything added:)

Just a quick announcement, if you visit our new website, http://obesitylawyers.squarespace.com/ You'll see an area for journaling. In addition to adding documents, research reports and sample appeals, we're also adding podcasts and videocasts. These will be topical and focus on appeals, denials, as well as nutrition, exercise. We have interviews scheduled with three bariatric surgeons, a personal trainner and nutritionist, as well as clients and patients alike. All free to give you a better understanding of these areas. Be well. Gary Viscio www.obesitylawyers.com