Randi

Prior to the making the appointment for the first return visit since I was unfilled, I rummaged through my post lap-band paperwork to call the surgeon's office to find out pricing information and to make an appointment. What I learned from that phone call is that the surgeon had "divorced" the old the bariatric program group and returned soley to private practice with his comrades. So, now the I was able to afford a visit to see my surgeon, the dietician, behavioral health and have a fill for $70. Because I was too embarrassed to see my surgeon after regaining all my weight, I decided to email him over the weekend at an address I came across on an old business card. He replied the same day and basically told me he was glad I had contacted him and to make an appointment to see him. He also told me that he felt his team could help me get back on track. So, I made an appointment first thing Monday morning for Wednesday afternoon of the same week to see my surgeon, the dietician and behavioral health. I knew I need a complete overhaul of mind, body and spirit. I had wasted enough time. After I checked in, my surgeon's physician assistant (PA) gathered all my history. I still felt uneasy about having regained all the weight, but I was there to come clean and restart my weight loss. So, I just gritted my teeth and beared all the questions and what appeared to be disapproving eyes. At one point in our discussion the question came up about why I had regained all my weight. I asked her honestly if she really wanted to hear all my excuses. She jokingly replied, "No," but I think we both knew nothing I said was going to change my current situation. Since my surgeon was already aware that I had regained the weight, I realized that everyone else was hearing it for the first time and didn't have time to adjust their reactions appropriately. The only reaction I cared about anyway was my surgeon's. He had had time to adjust. When my surgeon entered the room, I still felt uneasy. I didn't know what he would actually say to me knowing that I had not applied my best effort to lose as much weight as I could after banding, but he handled it well. He basically told me he was not going to beat me up because that wasn't his style. I told him, "I appreciate that." He told me that they were gonna check out my band to see if it was okay, and that he was going to run a series of bloodwork. I was then sent to the band adjustment room to check my band under flouroscope and to see how much saline was in my band. Fortunately, the band was still exactly where it should be and hadn't slipped, which was a relief. The PA was surprised that there was so much saline in my band. I mumbled something about my aggressive fill schedule, but I don't know whether she understood it or not, and I really didn't care. She also remarked on slowness of my esophageal function to the surgeon when I swallowed the barium, which my sugeon summised was due to swallowing pushing agains the pressure of the band. My surgeon took everything into considertation and decided to have the PA add .04cc to my band. So according to my calculations, I currently have a 3.6cc fill in my band, which breaks down like this: December 6, 2006/1.0cc December 13, 2006/0.6cc December 20, 2006/0.6cc December 27, 2006/0.6cc January 17, 2007/1.0cc January 25, 2007/0.6cc (unfill) January 23, 2008/0.4cc When I went to see Behavioral Health as part of my treatment plan, she told me stuff I already knew and wrote it down for me. I'm recording the list of things to do here for future reference. I also plan to enact some if not all of the suggestions. Here the list: Visual cues in refrigerator and pantry. Cordon off kitchen area. Do not go into the kitchen except to prepare meals and eat; have someone to do cleanup after meals Exercise five times per week; out of house preferably Plan menus for meals Journal The dietician visit surprised me because she was very obese. Mentally I questioned how she could advise me when it was so blatantly obvious that she was overweight. I flashed back to a time I considered becoming a dietician. However, I decided that if I couldn't keep my own weight in check, how was I going to help others. So, I braced myself to hear what she had to say and put my biases aside so I could better help me. As it turned out, she was simply the messenger. There to guide me based soley on published information provided by the surgeon and other sources. She directed me to pages within the guide she handed me so that I could see where I had gone wrong since my surgery. Guess what? I learned the only thing I was doing wrong was EATING! Imagine that. I had gotten so far away from the band rules that I was doing EVERYTHING in excess. I knew then that I was going to have to severly adjust my eating habits or as the saying goes, "If you always do, what you've always done, you'll always get what you've always got." What did I get? No surprise there -- I got FAT!

This past Wednesday, I finally returned to see my surgeon after a year. Most people will think the year I'm referring to is a year from the date I was initially banded. So, I need to clarify the "year" just a bit. I was banded on November 20, 2006. Yes, that's right, the week of Thanksgiving. It was total surprise to me too. From the time I made my first visit to the my Surgeon in October 2006 to the time I was notified of my surgery date was less than a month. The way my surgeon explained it to me is that since I was self-paying for the procedure, I could be moved ahead of the insured patients who had to wait on various approvals. Regadless of the reason, when the call came I was sitting at my desk with my mouth hanging open and my heart pounding in my chest. I thought I still had more time. I thought I would be able to have one last hurrah for over the holidays. I thought I had until at least January. I thought, I thought, I thought . . . But, ready or not on D-day, I was banded. By the time the middle of January rolled around, I was 20 pounds lighter. The reason is I was trying my best to stick to the guidelines my surgeon had given me and I was on an aggressive fill schedule. How agressive you might ask, take a look below: December 6, 2006/1.0cc December 13, 2006/0.6cc December 20, 2006/0.6cc December 27, 2006/0.6cc January 17, 2007/1.0cc January 25, 2007/0.6cc (unfill) That's right. After two weeks of recovery, I received a fill every week for four weeks, had another fill three weeks later. One week after the last fill, I returned to the surgeon's office to have some fluid removed from my band. For the record, I must say that last fill terrified me. I had done a lot of research on the band, surgeons, methods. I even watched a lap-band surgery being performed from start to finish online at the National Institute of Health website. I knew that every surgeon's aftercare requirement varied, even their fill schedules. My surgeon, however, stayed on the cutting edge of research and based on that infomation, he was filling patients sooner to alleviate hunger and faciliate weightloss. I was apprehensive. I had read no such information on such an agressive fill schedule. But I chose my surgeon because I trusted my him and I still do. So, I continued to return for fills as told until the fill on January 17th made me return a week later because I could barely swallow water. I knew something was wrong. As it turned out, I was overfilled. When some of the saline was removed, I was able to swallow again. I never returned to the surgeon's office after that. And, that's the "year" I needed to clarify. There are several reasons or rather excuses why I didn't return: A. The surgeon's Physician Assistant told me that I only need to return if I needed fills. I didn't think my surgeon would have totally agreed with that statement had he heard it being made, but it made a sort of half-way sense to me.[/b] B. I was self-pay and only had 90 days of services from my surgery date covered in my treatment plan by the surgery group. So, after the 90 days were up I was going to be the payee responsible for flouroscope fills and office visits including visits to the dietician. I didn't know how much that would cost, never tried to find out the final totals that would be charged for self-pay patients, and some part of me thought I couldn't afford it anyway. However, I was afforded the opportunity of four free visits to behavioral health within a year, which I never took advantage of because I had taken issue with a statement the counselor made and my pride wouldn't let me use the visits. C. I wasn't closely (or loosely for that matter) following the lapband guidelines. So, what sense did it make to return to the surgeon's office when I knew EXACTLY what I wasn't doing. D. We were selling and purchasing a home and I totally lost focus on me and was focusing on everthing and everyone but me. E. The contract I was on ended in September, which meant I no longer had a job. Who in their right mind pays for something they could only afford with a job after they lose their job? Not me. E. I was ashamed. I had paid all this money out-of-pocket and I still wasn't successful losing or keeping the weight off. I had regained it all. So, as 2008 reared it's ugly head. I was once again contemplating the same New Year's resolution about losing weight. I knew something had to change. I knew that "something" was me. On January 17th of the new year, I was given a ray of hope that I could now afford to go back to my surgeon's office and get back on track. My friend, Phia, sent me an email containing an article that my insurance carrier had officially announced that they were now covering lap-band. So, to me, it only made sense that they were now also covering fills and office visits. I called and made a follow-up appointment with my surgeon's office immediately.

TRICARE Now Covers “Lap-Band” Surgery January 16, 2008 No. 08-04 FALLS CHURCH, VA. – TRICARE beneficiaries whose weight poses a serious health risk now have a new surgical alternative available. For those who medically qualify, TRICARE now covers laparoscopic adjustable gastric banding, also commonly called Lap-Band surgery. Although the TRICARE policy change has only recently been made, coverage is retroactive to February 1st, 2007. “We at TRICARE are careful to only cover procedures that have been proven safe and effective, and are accepted by the medical community,” said Maj. Gen. Elder Granger, deputy director of the TRICARE Management Activity. “We’ve added this procedure because, for some beneficiaries, it may be the right course of action to preserve their health.” Granger adds that, like gastric bypass, gastric stapling or gastroplasty, Lap-Band surgery is only for those suffering morbid obesity. In medical terms, that means their body weight is 100 pounds over ideal weight for their height and bone structure, and their weight is associated with severe medical conditions known to have higher mortality rates. Body weight that is more than twice the ideal weight for the person’s height and bone structure may also indicate morbid obesity. In addition, TRICARE will cover the surgery if a patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery. Details of the coverage are available in the TRICARE Policy Manual, which beneficiaries can view online at http://manuals.tricare.osd.mil/index.cfm?fuseaction=TMAManuals.DisplayManualSeriesInfo&ManualSeries=POLICY&TP02=67#TP02. A search for "morbid obesity" goes directly to the correct section. About TRICARE Management Activity and the Military Health System TRICARE Management Activity, the Defense Department activity that administers the health care plan for the uniformed services, retirees and their families, serves more than 9.1 million eligible beneficiaries worldwide in the Military Health System (MHS). The mission of the MHS is to enhance the Department of Defense and national security by providing health support for the full range of military operations. The MHS provides quality medical care through a network of providers, military treatment facilities, medical clinics and dental clinics worldwide.

Hi, Amy, Tricare uses the Metroplitan Life Insurance Tables NOT BMI to determine whether you will be approved for surgery. I'm going to post links to the current Tricare Policy and a Metlife Table below for your reference. However, let your PCM/Surgeon be the one to determine whether you qualify: Current Tricare Policy: http://www.lapbandtalk.com/f8/tricare-now-covers-lap-band-surgery-49990/#post696335 Metlife Table: MetLife Height-Weight Tables

Trell, Tricare covers fills. The code for that procedure is HCPCS S2083 or CPT 90772. Since Tricare covers fills and your surgeon accepts Tricare (some don't), then your portion would be the co-pay. All my fills are done under fluoroscope at a cost of $70 for a fill/unfill, but I'm not sure of the CPT Code for that because it's a type of x-ray. However, fluoroscope fills is one of the criteria I used to select my surgeon. I didn't want to run the risk of a re-operation to replace punctured tubing or multiple needle sticks to access my low-profile port from the surgeon or the physician assistant doing "blind" fills. Fills under fluoroscope has made for a perfect "bulls-eye" everytime when accessing my port. I'm not grandfathered by the new Tricare Policy on banding. So, I've already had my PCM to submit a referral to try and get follow-up visits to include fills covered to reduce my portion of the payment to the co-pay. However, I live near two major MTFs -- Wilford Hall Medical Center and Brookes Army Medical Center. If either can provide follow-up treatment for the lap-band, it's likely Tricare may not pay for it.

RonWifey, I'm a low BMI bandster located/banded in S.A., TX. I only told a handful of people I was getting banded, but no one I worked with directly. When I told the ones closest to me, I told them in a way that let them know my mind was already made up and I could not be swayed. I had done all the necessary research on the procedure up to and including learning about the low-profile port option, finding a surgery group that held the "Center of Excellence" designation, and someone I trusted and felt comfortable with within that group to do my surgery. I remember reading surgeons bios, attending five seminars to personally meet and get a feel for the right surgeon for me. I don't regret the having the surgery and I've never looked back.

I just wanted to add to this most excellent post that this article was posted in all the major electronic military newspapers (probably a portal post). Here are the links: Air Force Times: http://www.airforcetimes.com/news/2008/01/military_lapband_tricare_080123w/ Army Times: http://www.armytimes.com/news/2008/01/military_lapband_tricare_080123w/ Navy Times: http://www.navytimes.com/news/2008/01/military_lapband_tricare_080123w/

I'm preband and considering becoming a possible self-pay patient with Dr. Spivak. I would like to know where Dr. Spivak placed your port, his rationale for port placement, and whether you have a low profile port. Also, if you have lost a substantial amount of weight, please tell me whether your port is visible based on the placement location.

Me, the lapband surgery CPT codes 43770 - 43774 are covered for what you plan to do. I was interested in Tricare paying for surgeon follow-up care and fills now and years after banding. My concern is that I self-payed for the procedure before Tricare approved the lapband and made the date retroactive to February 2007. So, really the question I'm trying to answer is, "Since I'm already banded, will Tricare now pay for any future fills and follow-up visits with my surgeon?" I'm hoping the answer to that question is "yes." However, I think there may be a little twist on the answer because Tricare will normally only pay for approved procedures that your MTF doesn't offer. At one time, Wilford Hall Medical Center here in San Antonio, Texas was doing banding and gastric bypass procedures. At the time I contacted them for banding, they were trying to get their banding program restarted and needed additional personnel to run that portion of their program. So, the response I might get from Tricare is that fills and follow-up visits must be conducted with the MTF. If that's the case, I'll have to decide whether I'm going to continue to pay out-of-pocket to see my lapband doctor or put myself in the hands of the military.

Michelle, I went to my surgeon's office today and was told I would have to get a referral from my PCM requesting authorization from Tricare for four visits over the next few months. The explanation I was given is that the surgeon's office can't bill unless the visits are authorized. Without that prior authorization, I'm on the hook for the bill. It just so happens that I have an appointment with my PCM in the a.m. So, I'll get to see first-hand how well this is going to work and post what I find out. My plan is to take a copy of the new Tricare policy with me to help things along and avoid the run-around.

You'll find that those who have been banded at lower weights are usually self-payers or qualify because they have a lower BMI with existing comorbidities. However, it really boils down to what your insurance policy will cover. Some policies are more stringent than others and require 6 months or more of supervised/documented diet and excercise before weight loss surgery will be approved.

Tricare uses POUNDS not BMI to determine eligibility. Hopefully, your BMI of 49 puts you in the weight range for coverage.

I live in Schertz adjacent to Selma.

Folks, As promised, below is the current Tricare policy as stated in their regulation. I'm assuming the items in red are the most recent changes since CPT 43770 is the procedure code for the lapband. I hope this information proves helpful or at least saves you a little research. Good luck to you all. TRICARE POLICY MANUAL 6010.54-M, AUGUST 1, 2002 CHAPTER 4 SECTION 13.2, Change 66 dated 12/10/2007; Change 67 dated 12/13/2007 SURGERY FOR MORBID OBESITY I. CPT PROCEDURE CODES 43644, 43770 - 43774, 43842, 43846, 43848, 43886 - 43888, S2083 II. DESCRIPTION Morbid obesity means the body weight is 100 pounds over ideal weight for height and bone structure, according to the most current Metropolitan Life Table, and such weight is in association with severe medical conditions known to have higher mortality rates in association with morbid obesity; or, the body weight is 200% or more of ideal weight for height and bone structure. III. POLICY A. Gastric bypass, gastric stapling or gastroplasty, to include vertical banded gastroplasty is covered when one of the following conditions is met: 1. 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. 2. The patient is 200% or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category. 3. The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown). B. In determining the ideal body weight for morbid obesity using the Metropolitan Life Table, contractors must apply 100 pounds (or 200%) to both the lower and higher end of the weight range. Payment will be allowed when beneficiaries meet all requirements for morbid obesity surgery including the ideal weight within the newly determined range. IV. EXCLUSIONS A. Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction. B. Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) for treatment of morbid obesity is unproven (CPTprocedure code 43645, 43845, 43847, or 43633). C. Gastric bubble or balloon for treatment of morbid obesity is unproven. D. Gastric wrapping/open gastric banding (CPT2 procedure code 43843) for treatment of morbid obesity is unproven. E. Unlisted CPTprocedure codes 43659 (laparoscopy procedure, stomach); 43999 (open procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum, and omentum) for gastric bypass procedures. V. EFFECTIVE DATES A. Laparoscopic surgical procedure for gastric bypass and gastric stapling (gastroplasty), including vertical banded gastroplasty are covered, effective December 2, 2004. B. Laparoscopic adjustable gastric banding is covered, effective February 1, 2007. - END -

Folks, If you're covered under Tricare, the important thing to remember is that Tricare does not use BMI as their standard for approving the procedure like many insurance carriers. So, if you don't meet the Tricare requirements you still may not be covered for the procedure even though the lapband is now a funded surgical procedure. When I get a chance, I'll go through my previous posts and repost Tricare requirements in this thread.

I pretty much avoid shrimp. For some reason, it just does not go down well. However, we made Crockpot Gumbo for New Years and I added raw shrimp the last 45 minutes of cooking. That was the best tasting shrimp I've had since being banded. It was so tender that had it been on a bone it would have fallen off.:biggrin2:

When you went from the band to VG, did your doctor use the same incisions or does your stomach look like a roadmap for the two surgeries?

I am in the same boat. I paid for lapband surgery out of my own pocket back in November 2006 and I'm doing absolutely nothing to keep myself from regaining the weight or to help myself lose the weight. The only bandster rule I follow the majority of the time is not drinking with my meals. I know I need to take one step at a time, but I feel a little overwhelmed when I think of everything I'll have to do to get back on track. I'm so embarrassed by my lack of progress and the weight I've regained that I haven't even been back to see my band doctor for a year. I'm not looking for sympathy, but I sure would like to hear from anyone who can relate and give me a pep talk.

I also had a hiatal hernia repaired at the time of band placement. So, I would say find another surgeon if this one is set on the RNY. Maybe he's just not skilled enough, which is a problem in and of itself.

Janiee, What I don't quite understand from your posts are the reasons why your husband is getting so mad at you that he's threatening removing you from his insurance policy. Obviously, he knows the surgery is important to you. So, is there something else going on that you're willing to share in this thread? Otherwise, any advice we offer you would be a shot in the dark. My husband became very quiet and withdrawn as my surgery date approached. Although I had opted for the least invasive weight loss surgery, one of the risks was death. I knew that; he knew that. We both had to deal with that fact in our own way. So, I can easily imaging that a husband who may not be comfortable with his wife having this elective surgery may "act out" in a way such as you described -- threatening to call the insurance company, removing you from the policy thus preventing the surgery. Problem solved . . . at least in his eyes. So, if you feel comfortable, please share the rest of your story.

For the surgery alone, I paid $15,500 -- Surgeon's Fee $5,900; Facility Fee: $8,500; Anesthesia: $900; Low-Profile Port: $200

Red Underwear Looks Extremely Sexy LOTUS

JPT, I understand not wanting to have anything cut or rerouted. That is one of the many reasons I chose the lapband. So, I just keep you in prayer hoping that the everything works out in your favor. Keep us posted.

Serious, Thanks for replying. Now that you mention it, I think I've heard of that procedure a while back. But, I can't for the life of me remember where. Anyway, I'll do a Google search and see what I turn up. For now, I think I may try the Colonix and see if my symptons subside. My main concern is the size of the pills. With my current fill, the size of the pill REALLY matters. I've already decided that if the pills are too big then I've probably have a whole lot of chopping or grinding to do in order to get them down. :faint:

JPT, I hope you don't mind. I'm just throwing out ideas that may help avoid having to have the bypass, an open procedure or both. Here's what came to mind when I read your post: If you can't get the surgery records ask if some type of barium swallow test or possibly an endoscope be done to determine the location of the mesh? Of course, I'm assuming the scar tissue from the repair would be evident with one of those methods. Also, if you have to resort to an open procedure, have you considered the Vertical Gastrectomy (VG). The VG is also referred to as the Vertical Sleeve or the Vertical Sleeve Gastrectomy. It's where a vertical portion of the stomach is entirely removed, but no intestinal rerouting is done. Here's a link for further info:(http://www.obesityhelp.com/forums/vsg/cmsID,8874/mode,content/a,cms/). If I ever have to have my band removed, the VG would be my Plan B.