Randi

Nathalie, I too am pre-band and want you to be be very, very, very careful. I have spent a lot of time in this and the www.obesityhelp.com forums and the trend is that the surgeon lays out the options and then the PATIENT decides. Now, sometimes the insurance carrier will only approve certain types of weight loss procedures and excludes lapband from their procedures list. However, it doesn't sound like this is the case for you. What I will tell you is that right now the push for many hospitals is to earn the "Center of Excellence" designation. I don't know all the criteria for the designation, but I wouldn't be surprised if the number and type of procedures performed is one of the criteria. When I specifically asked my surgeon which one she recommended for me. She said it was up to me, but given that insurance coverage wasn't a factor, she always suggests the lapband first and the RNY as the last resort. She told me that the gastric bypass has been the U.S. gold standard for many years and some surgeons prefer to perform that surgery exclusively. Considering surgeon's input, the extensive research I've done on both procedures, what I know about myself, what I'm willing to change, and what risks I'm willing to take with my life, I chose the lapband. Bottom line . . . this time it's not about what the surgeon wants. You're the conductor of this train. So, if the lapband is what you want and their still pushing you towards the bypass, find another surgeon or surgeon group that can talk to you openly, honestly and without bias about BOTH procedures. That way you'll feel confident you've made the right decision for Nathalie.

Pete, Your surgeon would be the first place to start on defining your initial goal, which I believe is usually to lose 50% of your excess weight. From there on, my guess is it's individual per person. Why don't you post a thread to ask the LBTers how they set their weight loss goals?

Pete, I would venture to guess that insurance companies look at the lapband from the standpoint of re-operation costs. After all, the band itself consists of three main components that can possibly break down -- band, tubing, and port -- not to mention all the other things that can go wrong -- can't be tolerated by the recipient, band erosion, slippage, stoma obstuction, etc. However, even with all that could go wrong, I'll take my chances with the band over the gastric bypass any day. Did you know that some people who have had gastric bypass are now getting the lapband implanted because they have regained weight and stretched the pouch created from the bypass? Undoubtedly, the adjustability of the band is a very appealing feature. It makes me wonder how many gastric bypass patients would have opted for the band if it was available at the time through their insurance companies?

That's probably quite true about Methodist being on the list. A few months ago, there were hardly any listed in Texas, but I noticed that this time there were quite a few more facilities that have since received the designation. BTW, I'm located in San Antonio and way before Medicare implemented their policy, the Methodist Hospital here had already received the designation. The only people who absolutely have to be concerned about the designation currently are those who use Medicare. If the facility is not designated a Center of Excellence, then Medicare won't pay for the surgery or the fills. One LBTer shared her story with us . . . Medicare had paid for the band, but between the time of her band being implanted and her first fill the new rule was implemented and she was unable to get her fill. I think she worked something out with her surgeon to get a fill, but it was tough going there for a while. In San Antonio, fills run about $200, but based where this lady was located her fills/unfills cost $650. Yikes!

Pete, There's only a handful of Centers of Excellence. Here's a link to the current list: http://www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp?filterType=none&filterByDID=-99&sortByDID=4&sortOrder=ascending

Dani, The tidbit of information about the contract change in January 2007 was given to me verbally by a Tricare Service Center representative, but I haven't seen it officially published anywhere.

Pete, Just make sure that your PCM uses the adjustable gastric band, CPT Code 43770. The lapband also has CPT codes for the fills and the pieces of the device should any portion of it need to replaced. From time-to-time, the insurance company confuses the band procedure with the gastric bypass procedure or one of the other band procedures. So, it's best to tell 'em exactly which procedure you want by code so you get a definite approval/disapproval for the surgery you want.

Pete, Were you able to confirm whether the Dallas VAMC will implant the lapband?

Dani, I am a Tricare Prime enrollee and recently submitted an application to receive VA medical benefits as well. My eligibility for VA healthcare is based on my percentage of service-connected disability. Currently, Tricare will not cover the Adjustable Gastric Band (lapband). So, you may want to verify and get it in writing that Tricare Standard will either pay or reimburse you for the procedure (CPT Code 43770). I was told the Tricare contract is scheduled to change in January 2007. So, perhaps the lapband may be covered at that time. Per current policy (http://manuals.tricare.osd.mil/), Tricare will cover Gastric bypass, gastric stapling or gastroplasty, to include vertical banded gastroplasty when one of the following conditions is met: ¨ The patient is 100 pounds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints. ¨ The patient is 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category. ¨ The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown). I'm not certain what the VA policy is to be eligible for surgery, but the medical standard is a 40 or greater BMI with or without comorbidities or at least a 35 BMI with one or more comorbidities. Each insurance company sets additional hoop jumping criteria. Tricare hoops are the 6 months diet and exercise regimen and the 100lb requirement based on the Metropolitan Life Insurance weight tables. Although depleting your 401k is definitely an option, there's a few other possibilities you may wish to explore. The first is locating Military Treatment Facilities in your Tricare region and contacting each one to determine if they're performing lapband implants (www.tricare.osd.mill), locating a Bariatric clinic that will finance the procedure at a discounted rate for self-pay patients (e.g. www.Wishcenter.org), or other finance options: http://www.lapband.com/lapband/costsandinsurance.do. Also, peruse this thread to see if there may be some different options to consider: http://www.lapbandtalk.com/showthread.php?t=19742 Honestly, I've considered the self-pay option myself, but have refrained from using it so far because I'm not ready to chance having to pay for a second surgery should implant removal become necessary.

Pete, Glad I could help! You may want to do some more research on your own. In one of those links it said that the Veteran had to be involved in the VA MOVE program or a similar program for three months as part of the pre-evaluation for surgery. Also, I don't know where you live, but the facilities that perform the surgery are limited. I'm hoping I can get referred out locally because the nearest facility to me is about 4 to 5 hours away from where I live. That could cause problems for me if I get a fill and then find a day or two later that I need an unfill. So, needless to say . . . research, research, research!

Pete, I did some research and it looks like the VHA does cover bariatric surgery for Veterans. Here are what I believe to be applicable links: http://www1.va.gov/SURGERY/page.cfm?pg=25 http://www.va.gov/move/download/Resources/BariatricSurgery/BariatricSurgeryHandbook.pdf#search=%22Veterans%20Health%20Administration%20bariatric%20surgery%22 http://www.va.gov/vatap/pubs/Bariatricfinalreport3-05.pdf

Pete, I'm investigating that very thing myself. In fact, I went and enrolled for VA healthcare today, because TRICARE will only approve me for the gastric bypass not the lapband. I know for a fact that CHAMPVA does pay for the lapband for veteran dependents and I'm hoping coverage for veterans is similar. I'm keeping my fingers crossed.

As far as I'm aware, he's new to the San Antonio area, but I believe he used to practice in Austin. Go to http://www.obesityhelp.com/morbidobesity/bariatric+surgeon+reviews+Nilesh+Patel+pbf.html to see what his patients had to say about him. I believe when I read up on him before, the reviews were favorable. However, based on his stats, he hasn't performed any lapband surgeries, you may want to verify this with his office if that detail is important to you. Oh, here's a link to take you directly to the patient reviews:

Yes, I formally met with Dr. Marquez in May. However, I chose her as my surgeon based on a seminar I attended in San Marcos. She struck me as knowledgeable, professional and caring. She has only done about 50 or so lapbands, but the most experienced lapband surgeon in the group has only done about twice that many. I guess they've been predominately a gastric bypass practice.

Unfortunately, I'm still waiting on my insurance company to "bless" the procedure with their agreement to pay. I hope to find out something shortly. Did you choose Dr. Marquez based on a friend's recommendation, after attending her WLS presentation, or was she assigned to you by someone in the surgeon group?

When you take the time to think about it, he's been holding up your life while making decisions about his. And more than likely, cheating you out of the love you deserve by lavishing it on someone else. Don't believe for one minute that his decision to leave and start over was made without careful thought and planning. However much he weighed is the weight and the burden that has been lifted from your life. Read the tag line below name. I believe it. I've lived it. I know it. God doesn't make mistakes. His leaving is the BEST thing that ever happended to you. You just haven't realized it yet, but you will. Now, wipe your tears and let yourself go . . .

July, turn up your speakers -- LOUD: http://www.hit-country-music-lyrics.com/George-Strait-She-Let-Herself-Go-Lyrics.html

Y'all really got me to thinking. So far, I've decided to use that fantastic money jar idea to save up for the spa day and treat myself at mid-goal. I'm also going to ask DH to treat me to a cruise or some other vacation once I reach goal. Now, all I need is some incremental goal ideas to keep myself motivated once I'm banded.

Hmmmm, since you didn't start the money jar a year ago, maybe you could go ahead and pay yourself $10 (or some other estimated amount) for every pound previously lost and then get on track saving for future pounds lost, exericise, and diet?

Do you have a count on the number of lapband surgeries he's performed? I researched him on OH, but he was only listed for RNY procedures and had no lapbands to his credit. But, the site is probably not as up-to-date as it could be.

How many Bariatric surgeons does the Center of Excellence facility in your area support? Maybe you can obtain a list of names from that hospital and contact one of those docs for a fill. I'm sure your surgeon will understand. It's unlikelly that he didn't know this change was coming months in advance. It's more likely that the practice took a look at how many Medicare patients they had with lapbands may be affected and decided it was an acceptable loss in revenue should the Medicare policy go into effect.

That helps your current surgeon not lose his patients to another facility, but how does that help you?

Dody,[/url] Being named as a Center of Excellence helps insurance members and patients identify and select Bariatric Surgery programs that provide comprehensive evaluation and care, superior clinical results, long-term follow-up regimens, demonstrated commitment and ongoing collaboration with participating hospitals. This designation takes into account extensive background information, including patient complication rates, combined with a one-day site visit to the medical center by a team of clinical experts. Source: http://www.northeastmedical.org/press_releases/bariatriccoe.html

Leenerbups, Call the approved facility and find out which doctors use their facility to perform bariatric surgery. You may find that you have "doc options" you hadn't considered. I doubt they would go to the extremes of getting the Center of Excellence designation for just one surgeon.

Leenerbups and all Medicare bandsters, dont' forget to rant here: :yell:http://www.house.gov/ :yell: