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Hi everyone I'm doing well since my banding on Sept 21. I'm on pureed food now - I was bored to tears with liquids only towards the end. I'm never eating Soup again in my life. I've noticed that I'm just not as hungry as I used to be. I used to think about food a lot, but I find that because what I can eat now is limited I think about other things. I have been cooking pureeing and freezing food for myself. I have never cooked ahead/planned ahead for meals in my life. I feel very grown-up and domesticated. :-) To be honest there have been some times when I have eaten food that isn't pureed. I had some sushi the other day and just chewed everything very slowly & well, with no problems. The main thing I am guilty of right now is forgetting to eat. But when I do eat, I find that I'm full/satisfied with a third of what I used to eat. It's just marvellous. I am having my first fill tomorrow. the weight loss seems to have plateaued off this week - I'm still sitting at 12 kgs weight loss. The main victory for me is that I have not had any alcohol since Sept 20. I used to drink excessively, which was the main reason for my obesity. I will never drink again - not having gone through this surgery. It would be insanity. It's so great to have moved forward without alcohol. I don't even miss it. I associate alcohol with bad health now.

Good Saturday Morning. I got up, fed the kitties and decided to weigh again. Umm, down another 1.5 pounds. Yup, I'm excited. Except for tonight is "Shit on your neighbor" Night. All those snacks and goodies. I hope I have strength. Getting ready to go to my monthly support group meeting at the Doc's office, I'm sitting here ready my e-mails and drinking my hot cocoa. One of the e-mails I opened was from my WW instructor informing me in a very beautiful letter, I mean very beautiful, heartwarming, extremely sad letter that her Mother passed away early this morning. The letter caught my breath and I am still teary eyed over it. I'm very sad at her passing but this letter really touched me. Irene, I am so anxious to follow you on your new journey and realized that there is no reason you can't post here. Isn't this the "Homeless" site? You have a home now and we welcome every bit of info you want to share with us. Who knows, maybe something that you are going thru will inspire one of us or someone that is lurking. I for one hope you hang here. Kat, that is a very sad story. Alcohol is such a destroyer of everything. Feelings, Family, Looks, Hopes, Dreams, Faith and all kinds of other things. I have a cousin who looked like she just stepped off a Vogue magazine who started drinking at an early age. It is horrible what the vodka has done to not only her self-esteem but to her Family and her beautiful looks. It's truly sad each month when we see her at breakfast, knowing that each time she gets up and swaggers to the bathroom that she is going in to take a hit off the bottle. I fear the her funeral is not to far down the road. Her liver is shot and they won't do a transplant in her condition. Such a terrible diesease. Kelly, Thanks for the compliment. It has been a struggle even with the band. However, without the band I would not be as succesful. I love my band and how we have gotten along. I fight with it daily but it's a good thing. Hopefully you and I will be off all of our diabete meds before long. I know that I fieel so much better just being off the blood pressure meds. I'm off to go dry my hair and get to my meeting. I'll see ya all soon.

Was a really strange night for me. I told Jenn about this, but will try to condense it.... I had a friend from grade school all through the years, she was without question one of my very best friends, we went through all kinds of things together. We went to court with one another trying to get child support from our ex's, she even lived with me at one point when we were young and she had nowhere to go. We talkd 2-3 times a week, and emailed daily---we were very close. We had DD's the same age, and our DD's had their kids 1 day apart! A few years ago, she was a single parent hitting rough times, we loaned her money, helped her move, bought her son some boots for work, just helped her again try to get on her feet. She has fought with alcohol abuse for years. So after helping her move, and settle in, I had gathered some things for the kids I thought she needed, and showed up to give them to her, and lo and behold, her live in boyfriend answered the door----MY EX HUSBAND!! Now I have no real issue with her being with him, other that she knew he was an a$$---but it caused serious problems with my DD and I. Once when Rick was out of town, he called me, the ex I mean, and he knew all this crap, and I jumped my DD over it, and when she said she didn't tell him I all but called her a liar! She was not the liar, my former friend was. And she knew---that was the kicker---I told her how my DD was sharing things with her Dad about me I didn't like, and she never fessed up, still hid it. I give her money--money she used to feed his worthless a$$, a man who never paid his CS to feed his child, and I fed HIM??? Nuh uh! I wrote it off, with friends like that, who would throw my child under the wheels of the bus to save their butts,who needs enemies??? So for years we have had no contact. I still see her family and all is well with them etc. Well she and my ex have been split for some time, he did the use and abuse and leave with her too--but he was not what ended the friendship---she did. Now.....finally the point. Her Dad died. I went to visit him in the hospital, and managed to avoid her, but tonight was the visitation, and I knew I would see her. We put off our trip to ABQ for it, we are leaving about 3 AM. So I saw her. OMG it was wierd! There was a mutual friend there with her when I saw her, which helped, and it was all good, there was no problem, but my goodness girls, the alcohol has destoyed her. Her clothes, and her hair were dirty, the veins in her face and eyes were broken. It was heart breaking. I thought to myself earlier today how glad I was for my band---I knew most of these people when I was very thin, then they all knew me at my fattest, so I was glad to feel comfortable in my skin again facing all of them with this "past" between us now. But weight was not the issue----it was so bizarre. I keep thinking, and hoping, it was shock, and sorrow, and all that had her so unkempt----I cannot convey how wierd it was that she was that way. You could smell booze.....so sad. Rick said it won't be long we will go to her services. I think he might be right. Sad. Suzanne-----I will surprise you with a call one of these days too!!! I interupted Tracy in LA, and interupted Jenn getting dinner for her kids.....I will catch you unsuspecting too!!! I called Jenn, because I felt bad, she spoke in the other room to people we thought of as friends, and was totally ignored. I recognized it, because it happened to me too. Was so much fun talking to her tho!!! Irene----girl you do what you need to do, to be happy and healthy, and if that is another, different surgery, then go for it! There is not a one size fits all cure for us.....so whatever it takes to find yours!! Rick took my wedding rings and had them sized as a surprise for our anniversary next month. They come back today and he could not wait!!! I love it! I love them, as much as I did back then!!! They were a size 9.5 according to the invoice, and now are a size 6! YAY!!!! I love them, I love him!!! Gotta go, or I will never make it up in the morning to go and will sleep all the way with the kids, and that isn't fair to Rick! LOL See y'all when I get back!

Made the visitation without issue, was smoothed over by a mutual friend (another of the "old" gang) being there with her when we arrived. We spent an hour or so sitting and visiting, with her, as well as with her family. Was extremely sad. Not just due to the loss of her Dad, who was a totally wonderful man, but my former friend looked bad. I know she has been through a hard time, but this is alcohol abuse related. That was hard to take. I had not seen her in awhile, and it was sad to me. I don't wish bad things for her, but she is not in good shape. We went to that, then to dinner, so now we will leave out waaaaaaaay early in the AM for Albq. I am talking middle of the night. But I needed to do this, and the kids can sleep in the car on the way. Will check in when we get back. Hope to hear great news from Ebony!!!

Here is the medical policy. The link was open one day so I copied it Does anyone understand D.....preprinted, check off forms are not acceptable. Does that mean my WW Book for the weekly weigh ins? E-Mail Us Medical_Policy@Horizon-bcbsnj.com Horizon BCBSNJ Uniform Medical Policy Manual Section: Surgery Policy Number: 022 Effective Date: 06/10/2008 Original Policy Date: 06/22/2001 Last Review Date: 11/25/2008 Date Published to Web: 08/11/2008 Subject: Surgery for Morbid Obesity Description: _______________________________________________________________________________________ IMPORTANT NOTE: The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member. Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment. __________________________________________________________________________________________________________________________ As indicated by its name, morbid obesity is defined as an increase in weight over optimal weight, which results in significant complications and a shortened life span. For example, morbid obesity has a significant impact on cardiac risk factors, incidence of diabetes, obstructive sleep apnea, and various types of cancers (for men: colon, rectum, and prostate; for women: breast, uterus, and ovaries). The first treatment of morbid obesity is obviously dietary and life style changes. Although this strategy may be effective in some patients, frequently the weight loss is not durable with only 5%-10% of patients maintaining the weight loss for more than a few years. When conservative measures fail, some patients may consider surgical approaches. A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as those patients with a body mass index (BMI) of greater than 40 kg/m2, or greater than 35 kg/m2 in conjunction with severe comorbidities such as cardiopulmonary complications or severe diabetes. Super obesity has been described as a BMI greater than 50 kg/m2. Surgery for morbid obesity, termed bariatric surgery, falls into three general categories; (1) gastric restrictive procedures that create a small gastric pouch, resulting in weight loss by producing early satiety and thus decreasing dietary intake; (2) malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the intestinal tract; and (3) combination of both restrictive and malabsorptive components. There are multiple variants of malabsorptive procedures, which differ in the lengths of the alimentary limb, the biliopancreatic limb, and the common limb, where the alimentary and biliopancreatic limbs are anastomosed. The degree of malabsorption is related to the length of the alimentary and common limbs. For example, a shorter alimentary limb (i.e., the greater the amount of intestine that is excluded from the nutrient flow) will be associated with malabsorption of a variety of nutrients, while a short common limb (i.e., the biliopancreatic juices are allowed to mix with nutrients for only a short segment) will primarily limit absorption of fat. The following summarizes the different bariatric procedures. 1. Vertical Banded Gastroplasty The stomach is segmented along its vertical axis. To create a durable reinforced and rate-limiting stoma at the distal end of the pouch, a plug of stomach is removed and a propylene collar is placed through this hole and then stapled to itself. Because the normal flow of food is preserved, metabolic complications are rare. Complications include esophageal reflux, dilation or obstruction of the stoma, with the latter two requiring reoperation. Dilation of the stoma is a common reason for weight regain. Vertical-banded gastroplasty may be performed using an open or laparoscopic approach. 2. Adjustable Gastric Banding This is the most commonly performed restrictive procedure. Adjustable gastric banding involves placing a gastric band around the exterior of the stomach. The band is attached to a reservoir that is implanted subcutaneously in the rectus sheath. Injecting the reservoir with saline will alter the diameter of the gastric band; therefore the rate limiting stoma in the stomach can be progressively narrowed to induce greater weight loss, or expanded if complications develop. Because the stomach is not entered, the surgery and any revisions, if necessary, are relatively simple. Complications include slippage of the external band or band erosion through the gastric wall. Adjustable gastric banding has been widely used in Europe. Currently, the Lap-Band Adjustable Gastric Banding System made by BioEnterics Corporation is an approved device by the U.S. Food and Drug Administration (FDA) for marketing in the United States. Another FDA-approved device is the REALIZE Adjustable Gastric Band For Morbid Obesity which is manufactured by Ethicon-Endo-Surgery, Inc. [Please refer to specific benefit coverage under the Federal Employees Health Benefits Program (FEHBP).] 3. Gastric Bypass with Short-Limb (150 cm or less) Roux-en-Y Anastomosis The original gastric bypass surgeries were based on the observation that post-gastrectomy patients tended to lose weight. The current procedure involves division of the stomach into a smaller upper (called the pouch) and larger lower sections in association with a Roux-en-Y procedure (i.e., a gastrojejunal and a jejujejunal anastomoses). Thus the flow of food bypasses the duodenum and proximal small bowel. The procedure may also be associated with an unpleasant "dumping syndrome," in which a large osmotic load delivered directly to the jejunum from the stomach produces abdominal pain and/or vomiting. The dumping syndrome may further reduce intake, particularly in "sweets eaters." Operative complications include leakage and marginal ulceration at the anastomotic site. Because the normal flow of food is disrupted, there are more metabolic complications compared to other gastric restrictive procedures, including Iron deficiency anemia, Vitamin B-12 deficiency, and hypocalcemia, all of which can be corrected by oral supplementation. Another concern is the ability to evaluate the "blind" bypassed portion of the stomach. Gastric bypass may be performed with either an open or laparoscopic technique. 4. Mini-Gastric Bypass Recently, a variant of the gastric bypass, called the mini-gastric bypass, has been popularized. Using a laparoscopic approach, the stomach is segmented, similar to a traditional gastric bypass, but instead of creating a Roux-en-Y anastomosis, the jejunum is anastomosed directly to the stomach, similar to a Billroth II procedure. This unique aspect of this procedure is not based on its laparoscopic approach but rather the type of anastomosis used. 5. Sleeve Gastrectomy A sleeve gastrectomy has been proposed to be an alternative approach that can be performed on its own, or in combination with malabsorptive procedures (most commonly biliopancreatic diversion with duodenal switch). In this procedure, the greater curvature of the stomach is resected from the angle of HIS to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum, and avoiding the dumping syndrome (overly rapid transport of food through the stomach into the intestines) that is seen with distal gastrectomy. This procedure is relatively simple to perform, and can be done by the open or laparoscopic technique. Some surgeons have proposed this procedure as the first in a 2-stage procedure for very high-risk patients including those who are “super” obese (BMI>50). Weight loss following sleeve gastrectomy may improve a patient’s overall medical status, and thus, reduce the risk of a subsequent more extensive malabsorptive procedure, such as biliopancreatic diversion. 6. Endoscopic Gastric Reduction or Transoral Endoluminal Gastroplasty The EndoGastric Solutions StomaphyX endoluminal fastener and delivery system was approved by the FDA on March 3, 2007 through the 510(k) marketing clearance as substantially equivalent to its predicate device, the Bard EndoCinch Suturing System. It is specifically indicated for use in endoluminal trans-oral tissue approximation and ligation of the GI Tract. The device uses vacuum to invaginate tissue through a port into a chamber and fasten it using H shaped polypropylene fasteners. It has been investigated as a possible minimally-invasive endoscopic procedure for patients who gain weight after bariatric surgery (e.g., due to a dilated gastrojejunal anastomoses after a Roux-en-Y procedure). 7. Biliopancreatic Bypass Procedure (also known as the Scopinaro procedure) The biliopancreatic bypass (BPB) procedure, developed and used extensively in Italy, was designed to address some of the drawbacks of the original intestinal bypass procedures that have been abandoned due to unacceptable metabolic complications. Many of the complications were thought to be related to bacterial overgrowth and toxin production in the blind, bypassed segment. In contrast, BPB consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure. The procedure consists of the following components. A. A distal gastrectomy functions to induce a temporary early satiety and/or the dumping syndrome in the early postoperative period, both of which limit food intake. B. A 200-cm long "alimentary tract" consists of 200 cm of ileum connecting the stomach to a common distal segment. C. A 300- to 400-cm "biliary tract," which connects the duodenum, jejunum, and remaining ileum to the common distal segment. D. A 50- to 100-cm "common tract," where food from the alimentary tract mixes with biliopancreatic juices from the biliary tract. Food digestion and absorption, particularly of fats and starches, are therefore limited to this small segment of bowel, i.e., creating a selective malabsorption. The length of the common segment will influence the degree of malabsorption. E. Because of the high incidence of cholelithiasis associated with the procedure, patients typically undergo an associated cholecystectomy. There are many potential metabolic complications related to biliopancreatic bypass, including most prominently iron deficiency anemia, Protein malnutrition, hypocalcemia, and bone demineralization. Protein malnutrition may require treatment with total parenteral nutrition. In addition, there have been several case reports of liver failure resulting in death or liver transplant. 8. Biliopancreatic Bypass with Duodenal Switch The duodenal switch procedure is essentially a variant of the biliopancreatic bypass described above. However, instead of performing a distal gastrectomy, a "sleeve" gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum, similar to the above procedure, to create the alimentary segment. Preservation of the pyloric sphincter is designed to be more physiologic. The sleeve gastrectomy decreases the volume of the stomach and also decreases the parietal cell mass, with the intent of decreasing the incidence of ulcers at the duodenoileal anastomosis. However, the basic principle of the procedure is similar to that of the biliopancreatic bypass; i.e., producing selective malabsorption by limiting the food digestion and absorption to a short common ileal segment. 9. Long Limb Gastric Bypass (i.e., >150 cm) Recently, variations of gastric bypass procedures have been described, consisting primarily of long limb Roux-en-Y procedures. For example, the stomach may be divided with a long segment of the jejunum (instead of ileum) anastomosed to the proximal gastric stump, creating the alimentary limb. The remaining pancreaticobiliary limb, consisting of stomach remnant, duodenum, and length of proximal jejunum is then anastomosed to the ileum, creating a common limb of variable length in which the ingested food mixes with the pancreaticobiliary juices. The stomach may be bypassed in a variety of ways, i.e., either by resection/division or stapling along the horizontal or vertical axis. Unlike the traditional gastric bypass, which is essentially a gastric restrictive procedure, these very long limb Roux-en-Y gastric bypasses combine gastric restriction with some degree of malabsorption, depending on the location of the anastomoses. Policy: [iNFORMATIONAL NOTE: When significant weight loss is achieved such as is typically the case after bariatric procedures for morbid obesity, it is not uncommon for the patients to be left with a significant amount of redundant skin (e.g., in the abdomen, breasts, thighs and arms). Procedures to remove the redundant skin are typically considered to be cosmetic. The eligibility of procedures and/or services related to, or resulting from, a prior surgical procedure for morbid obesity is determined by the patient’s specific contract benefits. When the patient’s contract does not specifically exclude such procedures and/or services, they are subject to review for medical necessity. Medical policies pertaining to the covered person’s condition should be consulted, as applicable (e.g., Policy #025 on Abdominoplasty, Policy #028 on Reduction Mammaplasty, and Policy #001 on Cosmetic Procedures including excision of excessive skin and subcutaneous tissue and suction assisted lipectomy, under the Surgery Section). The approval of a bariatric procedure for medical necessity should not be interpreted to be an automatic approval for procedures that address the sequelae of significant weight loss, nor should it create the expectation that such procedures will be approved.] I. Contract exclusions and/or limitations for surgery for morbid obesity (bariatric surgery) will determine the available benefit. [iNFORMATIONAL NOTE: Some contracts specifically exclude surgery for morbid obesity (bariatric surgery). Please refer to the group’s or individual member’s contract benefit language to determine benefit availability.] II. If it is NOT specifically excluded by the member's contract, surgery for morbid obesity (bariatric surgery) is considered medically necessary when all of the following lettered criteria are met: A. The surgical procedure is one of the following types: Laparoscopic adjustable gastric banding; [iNFORMATIONAL NOTE: Please refer to specific benefit coverage for adjustable gastric banding under the Federal Employees Health Benefits Program (FEHBP).] Vertical-banded gastroplasty; Gastric bypass with short-limb (i.e., 150 cm or less) or long-limb (i.e., greater than 150 cm) Roux-en-Y anastomosis; Biliopancreatic diversion and duodenal switch. [iNFORMATIONAL NOTE: According to the Consensus Conference Panel Statement presented at the Georgetown University Conference Center, Washington, DC, May 2004, "Standard of care for bariatric surgery includes use of laparoscopic and open techniques.] B. The member is at least 18 years of age and/or has reached full skeletal growth. Bariatric surgery is considered NOT medically necessary for members under 18 years of age unless the member has already achieved full skeletal growth and has a life threatening co-morbidity (i.e., pseudotumor cerebri, severe sleep apnea, uncontrollable hypertension, incapacitating musculoskeletal disease, etc.). [iNFORMATIONAL NOTE: According to published medical literature, bone age can be objectively assessed with radiographs of the hand and wrist.] C. The member has morbid obesity. Morbid obesity is defined as either: 1. A body mass index (BMI) greater than 40 kg/m2; or 2. A BMI between 35 kg/m2 and 40 kg/m2 with one or more of the following life-threatening, obesity-related co-morbidities which is (are) being treated or managed, and is (are) generally expected to be improved, curtailed, or reversed by obesity surgical management: coronary artery disease obesity-related cardiomyopathy congestive heart failure obstructive sleep apnea Pickwickian syndrome insulin resistance or frank diabetes mellitus clinically significant asthma chronic venous insufficiency of the lower extremities gastroesophageal reflux disease (GERD) pain and limitation of motion in any weight-bearing joint or the spine hypertension pseudotumor cerebri polycystic ovarian syndrome metabolic syndrome hyperlipidemia (hypercholesterolemia and/or hypertriglyceridemia) non-alcoholic fatty liver (NASH) osteoarthritis depression. [iNFORMATIONAL NOTE: BMI is calculated by dividing a patient’s weight (in kilograms) by height (in meters) squared. To convert pounds to kilograms, multiply pounds by 0.45 To convert inches to meters, multiply inches by .0254] D. Within the 12 months prior to the time of surgery, the member must meet all of the following requirements: 1. Documentation of successful completion of at least 6 consecutive months of supervised conservative weight loss program, diet programs/plans (e.g., Weight Watchers, Jenny Craig), or the Horizon Obesity Disease Management Program. Successful completion means formal documentation or photocopies/print-outs of progress notes of at least monthly follow-up by the supervising physician, other health care provider, or program coordinator including the patient’s weight and progress relative to the goals set at the start of the program. (NOTE: Pre-printed check-off forms and summary letters are NOT acceptable documentation for this requirement.) [iNFORMATIONAL NOTE: Programs supervised by a registered dietitian may not be a covered service under a member's contract.] 2. Documentation of participation in an organized multidisciplinary surgical preparatory regimen in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions. The regimen should provide guidance on diet, physical activity, and behavioral and social support prior to and after the surgery. Documentation should include physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen. 3.Documentation of pre-operative psychological evaluation provided by a licensed mental health care professional familiar with the implications of weight reduction surgery. (Please note that psychological testing is NOT included in this requirement.) [iNFORMATIONAL NOTE: It should be noted that all bariatric surgeries require a high degree of patient compliance. For gastric restrictive procedures the weight loss is primarily due to reduced caloric intake, and thus the patient must be committed to eating small meals, reinforced by early satiety. For example, gastric restrictive surgery will not be successful in patients who consume high volumes of calorie rich liquids. In addition, patients must adhere to a balanced diet, including proper micronutrient supplementation, to avoid metabolic complications. (Micronutrients are defined as Vitamins, minerals, and trace elements.) The high potential for metabolic complications requires life-long follow-up. Therefore, patient selection is a critical process, often requiring psychiatric evaluation and a multidisciplinary team approach.] III. The following procedures are considered investigational: Mini-gastric bypass Sleeve gastrectomy (either as a sole procedure or as one step in a staged procedure); Endoscopic Gastric Reduction (also known as transoral endoluminal gastroplasty). [iNFORMATIONAL NOTE: There is limited data published in the medical literature to evaluate outcomes of sleeve gastrectomy as a stand-alone procedure and to compare its efficacy with other procedures. Furthermore, the published data on outcomes following completion of both stages of a 2-stage operation are limited to case reports and case series with very small number of patients. According to the ECRI Health Technology Assessment Information Service Custom Hotline Response on Laparoscopic Sleeve Gastrectomy for Morbid Obesity (last updated 01/22/2007), “None of the studies reported weight loss at three years or more after the operation, which we consider the most important outcome measure for these studies to report. Earlier follow-up periods may not provide data indicative of the eventual results of the surgery and do not provide sufficient time to assess the possible long-term complications of this surgery”.] IV. Repeat bariatric surgery or any subsequent modification should be handled on an individual case basis and reviewed by the medical director. Supporting documentation should at least include a clear explanation of the clinical circumstances as to why the procedure failed, the member’s BMI, and the results of any diagnostic tests or studies performed. Since members are expected to be compliant with the postoperative requirements, members who have failed bariatric surgery because of noncompliance and wish to be considered for revision surgery must be actively reintegrated into an established multidisciplinary bariatric program. These patients must demonstrate compliance to the bariatric surgeon through enrollment in a multidisciplinary bariatric program including psychological intervention nutritional counseling, and support group attendance. A distinction between clinical failure and technical failure must be established. A. A clinical failure is defined as weight regain, inspite of an intact, functional operation. In these instances, reintegration into a multidisciplinary bariatric program and psychological re-evaluation are required. If the member is able to demonstrate the probability of complying with the postoperative requirements (e.g., diet , physical activity, etc.), repeat bariatric surgery or any subsequent modification of the original bariatric surgery may be considered medically necessary. Otherwise, any further surgical intervention is considered not medically necessary. B. A technical failure is defined as a breakdown of the operation itself (i.e., staple line disruption, fistula formation, dilatation of the pouch, marginal ulceration, band slippage, anastomotic dilatation, etc.). In these instances, psychological re-assessment of the patient is not mandatory. [iNFORMATIONAL NOTE: Band adjustment is a regular part of follow-up for adjustable gastric banding. All adjustments done within 90 days from band implantation are considered part of the global surgical service. Any subsequent adjustment beyond this period is eligible for separate reimbursement if the band implantation was deemed medically necessary.] ________________________________________________________________________________________ Horizon BCBSNJ Medical Policy Development Process: This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations. ___________________________________________________________________________________________________________________________ Index: Surgery for Morbid Obesity Adjustable Gastric Banding Banding, Gastric Bariatric Surgery Biliopancreatic Bypass Procedure Biliopancreatic Diversion Bypass, Biliopancreatic Bypass, Gastric Duodenal Switch, Biliopancreatic Bypass with Endoluminal Gastroplasty, Transoral Endoscopic Gastric Reduction Gastrectomy, Sleeve Gastric Banding Gastric Bypass Gastric Reduction, Endoscopic Gastric Restrictive Surgery Gastroplasty Lap-Band Adjustable Gastric Banding System Laparoscopic Adjustable Gastric Banding Laparoscopic Gastric Bypass Laparoscopic Mini-Gastric Bypass Laparoscopic Sleeve Gastrectomy Long Limb Gastric Bypass Malabsorptive Procedures Morbid Obesity, Surgery for Mini-Gastric Bypass Obesity, Morbid, Surgery for Scopinaro Procedure Sleeve Gastrectomy Transoral Endoluminal Gastroplasty Vertical Banded Procedures References: 1. Blue Cross and Blue Shield Association. Medical Policy Reference Manual: Surgery for Morbid Obesity. 5:2006: Policy #7.01.47 (and its associated references). 2. ECRI. Health Technology Trends. FDA clears stomach band for obesity. Vol.13 No.7. July 2001. 3. Weiner R, Bockhorn H, Rosenthal R, et al. A prospective randomized trial of different laparoscopic gastric banding techniques for morbid obesity. Surg Endosc. 2001 Jan;15(1):63-68. 4. Cadiere G, Himpens J, Vertruyen M, et al. Laparoscopic Gastroplasty (Adjustable Gastric Banding). Semin Laparosc Surg. 2000 Mar;7(1):55-65. 5. Fielding GA, Rhodes M, Nathanson LK. Laparoscopic gastric banding for morbid obesity. Surgical outcomes in 335 cases. Surg Endosc. 1999 Jun;13(6):550-554. 6. Dargent J. Laparoscopic Adjustable Gastric Banding: Lessons from the First 500 Patients in a Single Institution. Obes Surg. 1999 Oct;9(5):446-452. 7. Belachew M, Legrand M, Vincent V, et al. Laparoscopic Adjustable Gastric Banding. World J Surg. 1998 Sep;22:955-963. 8. Improvement of physical functioning of morbidly obese patients who have undergone a Lap-Band operation: one-year study. Obes Surg. 1999 Aug;9(4):399-402. 9. Furbetta F, Gambinotti G, Robortella EM. 28-month experience with the lap-band technique; results and critical points of the method. Obes Surg. 1999 Feb;9(1):56-58. 10. DeMaria EJ, Sugerman HJ, Meador JG, et al. High Failure Rate After Laparoscopic Adjustable Silicone Gastric Banding for Treatment of Morbid Obesity. Annals of Surgery. 2001 Jun;233(6):809-818. 11. National Institutes of Health. Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Int Med 1991;115:956-61. 12. MacLean LD, Rhode BM, Forse RA. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 1990;107:20-27. 13. Willbanks OL. Long term results of silicone elastomer ring vertical gastroplasty for the treatment of morbid obesity. Surgery 1987;101:606-10. 14. 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A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweet eaters. Ann Surg 1987;205:618-24. 22. Fobi MA, Fleming AW. Vertical banded gastroplasty vs. gastric bypass in the treatment of obesity. J Natl Med Assoc 1988;78:1091-98. 23. Doherty C, Maher JW, Heitshusen DS. Prospective investigation of complications, reoperations and sustained weight loss with an adjustable gastric banding device for treatment of morbid obesity. J Gastrointest Surg 1998;2:102-08. 24. Doherty C, Maher JW, Heitshusen DS. An interval report on prospective investigations of adjustable silicone gastric banding devices for the treatment of severe obesity. Eur J Gastroenterol Hepatol 1999;11:115-19. 25. Miller K, Hell E. Laparoscopic adjustable gastric banding: a prospective 4 year follow up study. Obesity Surg 1999;9:183-87. 26. Suter M, Giusti V, Heraief E, et al. Eary results of laparoscopic gastric banding compared with open vertical banded gastroplasty. Obesity Surg 1999;9:374-80. 27. Scopinaro N, Gianetta E, Adami GF. Biliopancreatic diversion for treatment of morbid obesity: Experience in 180 consecutive cases. Obesity Surg 1999;9:161-65. 28. Nanni G, Balduzzi GF, Capuluongo R, et al. Biliopancreatic diversion: Clinical experience. Obesity Surg 1997;7:26-29. 29. Murr MM, Balsiger BM, Kennedy FP, et al. Malabsorptive procedures for severe obesity; Comparison of pancreaticobiliary bypass and very long limb Roux-en-Y gastric bypass. J Gastrointest Surg 1999;3:607-12. 30. Grimm IS, Schindler W, Halusza O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1992;87:775-79. 31. Langdon DE, Leffingwell T, Rank D. Hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1993;88:321. 32. Sugarman HJ, Kellum JM, DeMaria EJ. 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Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002 Aug;12(4):564-8. 41. Rubensteing RB. Laparoscopic adjustable gastric banding at a U.S. center with up to 3-year follow-up. Obes Surg

How do you chew forty times? Wow I can barley get in 20 times. I also don't drink for an hour after I eat and that gets easier as time goes by. Good thing to give up cokes and alcohol too. I have missed my diet coke so much. I only drink water day and night since I can not find something that taste good. Your doing good!!!

Yes, you can drink alcohol, but you have to remember you are drinking calories. Empty calories.

I am looking into getting the surgery done but i just have a few questions. If you were to have the surgery are you allowed to drink alcohol after the surgery?

I am looking into getting the surgery done but i just have a few questions. If you were to have the surgery are you allowed to drink alcohol after the surgery?

186.5 for me today. I was away for check-in last week, but had gone up 2 pounds to 189 (that stress must have been catching that week). So with a little pre-planning I lost those 2 I'd gained and another .5 pound ON VACATION last week...simply amazing...6 days of every meal out and lots of alcohol (yes, I did) and I lost weight. I love my band! GO BUNNIES!!!

thanks everybody. Well the good news is my mom and I are very close. We can talk anything or joke about anything. I was a very tough kid to deal with and I pretty much rejected authority. As a young adult I found myself in a not so good place. When my chips were down I called her for help and she was there. With her help I dusted myself off and started a new life literally. Through the years I have thanked her many times. Maybe I use that to her advantage. The bad news is she is the type of person who is scared to death of anything. That may have even saved her life once. I was young but I remember the phenphen craze and her saying h@# no I'm not taking that stuff. Smart move. She's never smoked. Has never in her life drank alcohol, no drugs. I know her and she's also affraid she will find out bad news about her health other than the obvious. Its going to be hard and take a lot of work. I will look into a seminar immediately. Someone had mentioned to me something about being too big for surgery. That she may have to loose x number of lbs before she would be elligible? These type forums are excellent. I want you guys to know that. When I quit smoking seven years ago my support group was a user forum kinda like this. Its hard to explain how helpful it was.

I continue to practice. Back to that in a minute. I got my approval to go to the Seminar. It's this Saturday and my surgeon is Dr. Oliak in Orange, CA. After that, they submit my paperwork to be approved for the surgery. That should take about two weeks. From that date it should be about one month till I'm banded. I continue to lose weight on a 1200 cal diet with very healthy choices. Some things that I'm having trouble with are: chewing...I try to chew everything 40 times but it's so darn hard!...I use a timer that sits in front of me and I MAKE my meal last 30 min. Of course, no liquids with meals and none for 1 hour after. That is hard too! I know I'm whining but isn't that what these forums are for? And I'm hungry. Exercise is difficult and slow. I tire sooo easily. I need knee replacement surgery so I am limited. Any ideas? I've been biking, rowing and working a few machines at the gym that are low impact on the knees. I've only been at it for around 7 days. I did pick up a protien shake at Costco. They also have these berry/yogart packets made by Yoplat. I highly recommend them. They're in the frozen foods dept. Well I'm off now. Thanks to all you great people out there I'm doing what I'm supposed to before I see the surgeon. Any other suggestions would be greatly appreciated. Oh...and I quit drinking alcohol and diet soda!

Hi Helen I too am a food addict, I love food, every single bite. But food does not love me. I've struggled for 25 years just like you have. I just can't do it alone. Has the sleeve cured your addiction? Do you still crave all those foods you used to LOVE? Is the emotional stress tolerable? Do you get depressed because you can't eat? And what do you do instead of eating? I am not morbidly obess, I'm what ya'll call a "light weight" My BMI is 39 and I'm 235 lbs. But I'm only 5'5" and should weight 135. This extra 100 lbs. effects everything, my back, my knees, my breathing, my sex life, my heart. I want to be normal again !!!! Do you regret any of it? Do you miss eating? I fear I will....be depressed when I'm in a room full of people gorging themselves on Christmas dinner etc. To me it would seem like avoiding the Bars if your an alcoholic, but how do you avoid food? SO many thoughts, so much to think about.........

One thing to keep in mind that I never thought about until now: I am having issues with my pancreas. I am a drinker and have only been drinking on a regular basis for about 2 years. Obesity and significant weight loss can bring on gallstones and excessive alcohol consumption can directly affect the gallbladder and the pancreas. Just something to consider

I used to drink quite a bit (whatever that means--1 or 2 a day, maybe more on weekends), but have cut down since surgery. I don't have restrictions from my doctor (or the band itself) on alcohol, but I keep in mind the liquid calories! Plus now I'm not really used to drinking as much. I have anywhere from 0 to 3 drinks most weeks; sometimes I want more, but usually the calories keep me from doing it! And even on special occasions, I try not to drink too much; there is NO way I want to drink to the point of getting sick with the band--I cringe when I think of how unpleasant and dangerous that would be.

Libby's right. You'll still be able to drink wine. You're not supposed to drink with your meals, and some people experience pain when drinking with a meal, but others don't. So, chances are, you won't get a negative response from it, except for all the additional calories. I'll have to warn you, that if you have a food addiction, some people transfer their food addictions to other addictions like alcoholism. If you think you're possibly a borderline alcoholic or if you exhibit addictive behaviors, you need to seriously address this before surgery. Good luck to you, and I hope it all works out for you.

I'm new here and I have at least until January until I can get banded. I currently drink pretty heavily. I'm hoping that the band can help me curb the wine drinking as well as it does with foods. Is it possible that the band will restrict how much wine I can drink?

There's no need to get so personal. Yes it's illegal. But no it is not as bad as alcohol or cigerettes or caffine for that matter. It's hard to reverse decades of propaganda out of peoples' minds. Also for the person that assumed they were talking to someone young, I find that demoralizing and extremely deragatory. It is possible to have logical reasoning skills at a young age. And it's also possible to be a self righteous bigot without consciously knowing. Both sides are being condescending towards each other and it's just wrong. There are many people out there that have the wrong information about marijuana. And likely the only reason why it's illegal both recreationally and medicinally is because it's politics. There are no politicians that are willing to put their careers on the line to stand up for it. Those politicians that do stand up for it have other differing views that keep them from being elected.

I smoke marijuana probably more than anyone else on this board (to be honest every single day) and I'm doing GREAT on my journey. it's all about WILLPOWER! Weed doesn't make you gain or loose weight, YOU DO. Don't insult people because they smoke weed. I don't insult people on here because they smoke cigarettes or drink alcohol. That's their choice.

I don't mind at all. I am a psychiatrist and work as an adjunct with law enforcement at a maximum security prison. I have not *done* any studies, but have read the work of other experts who have done research. There is no correlation between 'popularity' and safe use. :thumbup: Again, let me reiterate that I don't have a prejudice against marijuana. My belief is that we either make it legal...or make cigarettes and alcohol illegal. Let's at least be consistent. In any case, it torques me that it is taking so long to get marijuana approved nationwide for medical purposes. The research is there to back up its efficacy for a number of medical problems...not the least being pain relief and without the addictive qualities of so many other pain relievers.

When I saw that you'd just posted, I was so excited. He's back!! I came to this place after you were long gone, but through random clicks on miscellaneous blogs, had come across one of yours. It touched me so much, that I then went back and read each and every one of them, amazed at your prowess with words, amazed at how I could relate to so much of your emotion. You have a succinct way of exposing your underbelly in such a shoot-from-the-hip manner. Then as I got to the end of your posts, and you said you had nothing else to say and was leaving, I felt saddened -- because you, like no other, get to the absolute heart of things for us all. I was hoping as I began reading your latest post that it would be filled with the halleluiah's and whoops and whistles from your most recent victory over the hunger demons -- but, of course, that wasn't what I found. Once again, I found a straightforward heartfelt post that we can all relate to in one way or another. I can very much relate to your relationship with alcohol. It's all so familiar to me - "Am I an alcoholic, am I not -- maybe I can just drink more like a lady if I try harder, maybe if I just switch to beer and lay off the hard stuff." All of that internal dialogue I was intimately familiar with for about 25 years. Five and a half years ago, I realized that the label didn't matter, it all boiled down to one thing: alcohol was prohibiting me from being the person I wanted to be -- somebody that I could be proud of -- and I quit. Yep, have not had a drink since. I was sick of it all, and finally found some internal source of power that told me to stop all the messing around and get to the task at hand -- changing my life and stop all the crap feelings telling me I had no choice in the matter. I found an online sponsor to help me with some of the AA stuff, and got on with discovering who I was without alcohol. I can tell you that it is all TOTALLY relevant and runs concurrently with our food issues. I know that many of us will spend our lifetime digging down there to find out the root of it all. The whole point of it is -- when you decide, really decide, that you want to make a change in your life, whether it be alcohol, overeating or other poor life choices -- you most certainly have the fortitude to do it. Just take the steps to make these changes, and they will happen. What I've discovered for myself is that life goes by so quickly. As friends and family members die, this realization is solidified for me. And I, for one, have decided that I'm not going to let another day, month, year, DECADE go by being somebody I don't want to be and feeling like I'm the victim. A very wise man (okay, my oldest brother) once told me years ago, "You're in a deep hole, waiting for somebody to throw you a rope, and you can't even see that there's a ladder right there next to you." May you find your ladder. And please keep posting -- you add such texture to this site. Cindy

I'm not a smoker of any variety. I believe if pot is illegal, then cigarettes and alcohol should be as well. They're far more destructive and addictive than pot as proven to be. I know many people on a personal level who use pot and are extremely high functioning intelligent people who are quite successful at the careers they've chosen. All that said, pot is illegal and it amazes me that the owners of this site have no problem with promoting illegal behavior. As for those who choose to break the law so publicly...at least when you get caught (post banded), you'll have the consolation that you'll look so much better in those prison jump suits than you did pre-banding. .

Hey LilMiss, The issues you are having - are you sure that cancelling the unfill was best? I REALLY hate to think that you might be doing some damage to your system through your nightly coughing. The appointment with the nutritionist can't do any harm, and may be beneficial, but I worry about your coughing. The sweet demon isn't my enemy - but those high fat Proteins are doing me in! Nuts, nuts and more nuts! I know that some of my weight gain can be attributed to the empty calories of alcohol (I went from one glass of wine a week, to having multiple glasses almost every day while on holiday). BAH!!! That is easily controlled. But the need for proteins, and my loves of all things nutty and cheesy are going to be a bigger struggle. How is everyone else doing? Roll call: Shiny, Ezma; Marathinner; Angie; Lori; Jul; RSG; St Louis; CKK;TSK; Mom; and others.

Wow, I seems that ur going through a whole lot of different issues and drinking is ur escape , ur not alone lots of people are also go through the same thing they just don’t have enough courage to say it or write it out loud just as u have ! My husband is also shy and he drinks because he also feels he helps to loosen him up, however I try to tell him that I enjoy that person that he is and that he must learn to feel confident in his own skin and who he is without anything altering his personality, I would say the same for you!!! You need to get to know u and who u r without food or alcohol and learn to embrace that!! I am sure Ur a great person also surround Ur self with positive people and positive things!!!! Take care and I hope these words help!!! awill

I’m suffering. I’m rubbish. I’m a failure. I can’t do it. I didn’t think I should write about this on a weight loss surgery blog as it doesn’t entirely have relevance. Especially as I signed out almost two months ago saying I wouldn’t be writing any more. Ah, but how the slow winter nights of insomnia have a way of thrusting the urge to splurge upon one’s frame. So, why am I suffering? Why am I rubbish? A failure? And what exactly can’t I do? All will be revealed in the next exciting paragraph. With as much stalling as I can muster – I am slowly coming to the painful realisation that I might well be an alcoholic. Ouch. Did I say that? Well – I may not be an alcoholic, but indeed I am a heavy drinker. All who know me and love or hate me will vouch for that very fact. But when it comes to being a true alcoholic – the definitions seem so muddy, I am not sure. Or am I? I have no withdrawal symptoms when I stop and I am not dependent, but – I continue to drink despite the negative social effects, despite the financial drain on my less than healthy financial state and despite the effects it has on my health. This is where I am stretching the relevance to a weight loss issue. But lately, I am wondering whether it is more closely linked than I initially thought. Over the last few months, my progress into the halls of The Temple of Normal BMI has halted. My eating has lessened and my exercise has increased. My drinking has also picked up a tad. Goddammit, there lies the big bloody bastard bugger-face staring me straight in the eyes. I know it’s there. I can see it plainly and simply. Alcohol is causing me to not lose weight, despite being over-tightened on the band front. Alcohol is causing me to slowly lose friends. Alcohol is causing me to lose money. Alcohol is having great effects on my family life and alcohol is causing me to hate myself. So you can see the attraction I have to it, eh! I am writing this because I am so disappointed in myself and have used this outlet to vent and eventually feel better about the problems at hand. However, I don’t think this problem is going to be sorted by vitriolic venting. What has become clear in this whole gastric band journey is the addiction I had to food – and probably still do. You may well catch me of an evening desperately trying to eat a juicy steak. After each mouthful – running to the lavatory to expel what I have just swallowed as my band is currently just a little too tight. I could easily eat less cumbersome things to ensure ease of passage – but I want the steak. And I will return to the plate and repeat the same procedure perhaps four or five times. Because the band hasn’t cured my need to satisfy my desire for flesh! But it has offered me a way to control it should I so desire. It has helped me realise my addiction more than anything else. A knowledge which I am grateful for; but sometimes a little foolhardy with. I have so far, despite my pitfalls and apparent bulimic state, been relatively good with all other food (I won’t bore you with my chocolate rushes). Booze on the other hand has no control in place. I am at its mercy. In fact, I am at MY mercy. Let’s face it – I decide when to drink – I am aware and I am fully conscious of what it is doing. I was under the grand illusions as I started to lose weight that I would quit drinking. I know the reason I do it and it is sadly very simple. I do it because I am terribly shy. When I have had a drink however, I am quite the opposite. I become bombastic, gregarious and hugely annoying and people, despite their best efforts, can’t fail to notice me. Something in me likes that. The shy retiring giant hates being shy and retiring and craves people to remember him. Even if it means the memories for them are bad and the memories for me are non-existent. I figured it would be the end to my drinking because I wouldn’t be so shy. Losing weight would give me more confidence and make me more outgoing and allow me to stand tall and have conversations with people on an equal standing knowing that they were talking to a person, not a walrus. But, such is life that when a walrus loses weight – it is still a walrus. I am still painfully shy and I still find it difficult to talk to people. Maybe years of fatness have ingrained shyness into my psyche or maybe I am just shy because I am. The gastric band has given me a great opportunity to overcome some of my demons. An opportunity that I sometimes abuse and take for granted – time has a wonderful way of letting one forget their blessings. What it hasn’t done is offer me a cure for all of my other failings. Perhaps writing this will be the first step on another journey of self-discovery and perhaps it will just be another piece of prose that adds to my posthumous biography that will never be written. I decided to write this because I do feel it is of relevance to people considering having the surgery as it has shown me that I was perhaps a little over-eager to consider it the answer to my problems instead of a pretty good guide to help me find my own answers – a guide that is sometimes ignored. So, after that marathon outpouring of in most angst and in summation: I’m suffering - yes I am, but I am admitting I need help, so my suffering on that side of things is perhaps no longer in silence and it may well help my future efforts. I’m rubbish - yes again. But, I know I have a way to crawl out of the trash can. It’s just up to me to do it. I’m a failure - not entirely, because it’s not yet over. Maybe I can turn things around. I can’t do it - Yes I can. Originally posted at: www.lapbandblog.org.uk