bcbs denial today-?? as good as gastic bypass

[mila1013 0]

hi all,

Today my denial came for the sleeve. It states:

"based on the clinical information provided, our medical director has determined that this request is not medically necessary. According to the BCBS Medical Policy for Bariatric surgery, Laparoscopic sleeve gastrectomy is considered not medically necessary as the literature does not support that this alternative procedure demonstrate both that it improved the net health outcome, and that the overall benefit/risk ratio for the procedure was at least as good as gastric bypass."

so while they say not medically necessary it is actually a investigational/experimental denial.

Does anyone know of articles that state that sleeve is at least as good as gastric bypass? thanks all in advance for your help

Mila

[Papillon 7]

talk to your surgeon's office they may be able to appeal... sorry you have to go through more approval stuff..

[Sunshine 1]

It's your group that's the problem. Some of BC/BS groups DO pay for this. My group did NOT pay. So, I had to pay out of pocket.

You have two choice (from what I can tell). You can have your Dr appeal it, or you can go to whatever company you have your insurance through, and ask them to accept it.

[KabinKitty 11]

This is an article from the Amerian Society of Metabolic and Bariatric Surgery:

http://www.asmbs.org/Newsite07/resources/Updated_Position_Statement_on_Sleeve_Gastrectomy.pdf

This is an article I found on another site:

The VSG is the Vertical Sleeve Gastrectomy or Gastric Sleeve, a newer type of WLS in which most (approximately 85%, depending on the surgeon and patient) of the stomach is permanently removed, leaving a slender "sleeve" of stomach about the size of a Sharpie marker, with normal connections between esophagus and stomach and stomach and small intestine.

At one time, it was performed most commonly as the easier, less-invasive first stage of a two-stage procedure (the second stage being a Duodenal Switch, for example) on super-super obese people (BMI above 60) who were not physically in good enough shape for a RNY. After losing the first 100 or more pounds post-VSG, the patients were then fit enough to go through the second surgery to lose the rest of their excess weight. Presently, it's also done as a stand-alone WLS procedure on people who have less weight to lose, and the surgeons are finding that many people with high BMIs like mine lose all the weight they need even without a second surgery.

The sleeve, like a RNY pouch, cuts gherelin production (which suppresses physical sensations of hunger), but unlike the RNY pouch, it still produces stomach acids so that meds (including anti-inflammatories) can still be taken normally once the sleeve has healed post-op. The VSG procedure is strictly restrictive, like the LapBand, rather than restrictive and malabsorbtive, like RNY, so calories and nutrients are better absorbed during digestion. Nutritional supplements are still necessary, however - I have to take the same Multivitamins, Calcium, Iron, B12, etc. as RNY patients, although I could get my Calcium as carbonate rather than citrate (I don't - I use the same calcium citrate products as everyone else here on TT). The surgery is irreversible, unlike the LapBand, but has a better weight loss rate than LapBand - more like RNY.

Most insurance companies don't cover VSG yet because they still consider it "investigational", but it tends to have a lower complication rate because it's a simpler procedure and many WLS surgeons believe it will eventually be widely performed.

Through my own research, I have found some information which would be helpful to those considering WLS. This is neither authored by nor endorsed by the owners of this forum but is simply the gathering in one place some useful information I personally have come across.

Let's look at an overview of the major WLS options out there:

http://www.thinnertimes.com/weight-l...omparison.html

http://www.lapsf.com/weight-loss-surgeries.html

Restrictive versus Malabsorptive Surgery

There are a number of weight loss surgery procedures available to treat obesity. Bariatric surgery has two primary approaches to achieve weight loss, and treatment typically emphasizes either the restrictive or malabsorptive approach or a combination of the two.

Restrictive Weight Loss Surgery

This type of bariatric surgery involves closing off parts of the stomach to make it smaller, thus decreasing the amount of food that can be eaten. The LAP-BAND?, Vertical Sleeve gastrectomy and Vertical Banded Gastroplasty procedures are restrictive types of bariatric surgery.

LAP-BAND? Surgery

The Laparoscopic Adjustable Gastric Band procedure, more commonly known as LAP-BAND? surgery, is growing in popularity. This restrictive procedure involves using a Silastic? band to create a smaller stomach pouch, causing patients to become full after eating a minimal amount of food.< /p>

Vertical Banded Gastroplasty (VBG)

The Vertical Banded Gastroplasty weight loss surgery procedure creates a smaller stomach pouch by stapling off a section of the stomach, then using a band to restrict the passage of food out of the pouch. After stomach stapling, the patient is unable to consume large amounts of food in one sitting. Once the food leaves the pouch, it goes through the normal digestive tract.

Malabsorptive Weight Loss Surgery

This weight loss surgery approach entails altering the digestive system to decrease the body's ability to absorb calories. The Biliopancreatic Diversion and Extended (Distal) Roux-en-Y Gastric Bypass procedures are malabsorptive types of bariatric surgery.

Biliopancreatic Diversion (BPD)

Biliopancreatic Diversion involves first creating a reduced stomach pouch and then diverting the digestive juices in the small intestine. The first part of the small intestine, where most of the calories are normally absorbed, is bypassed. That section, which contains the bile and pancreatic juices, is reattached to the small intestine much further down. There is a variation of this procedure called Biliopancreatic Diversion with "Duodenal Switch." This operation utilizes a larger stomach "sleeve" and leaves the beginning of the duodenum attached, but is otherwise very similar to standard BPD.

Extended (Distal) Roux-en-Y Gastric Bypass (RYGBP-E)

This weight loss surgery procedure is a variation of the Roux-en-Y Gastric Bypass operation. It differs in that a somewhat larger stomach pouch is created, but a significantly longer section of the small intestine is bypassed. There is less emphasis on restricting food intake quantity and more on inhibiting the body's ability to absorb calories.

The Combined Approach - Restrictive and Malabsorptive Surgery

The Roux-en-Y gastric bypass procedure is a combination operation in which stomach restriction and a partial bypass of the small intestine work in tandem as one of the most effective treatments for severe obesity.

Roux-en-Y Gastric Bypass

The most commonly performed weight loss surgery in the United States is Roux-en-Y Gastric Bypass. This operation involves severely restricting the size of the stomach and altering the small intestine so that caloric absorption is inhibited.

Open versus Laparoscopic Surgery

There are also varying techniques that can be used during bariatric surgery procedures. The two techniques are laparoscopic and open bariatric surgery.

Open Bariatric Surgery

While laparoscopic bariatric surgery can be performed through several small incisions in the stomach area, open bariatric surgery requires one larger incision that begins directly below the patient's breastbone and ends just above the navel. While both the open and laparoscopic procedures produce similar long term results, open bariatric surgery is associated with a longer recovery period.

Laparoscopic Bariatric Surgery

As opposed to "open" bariatric surgery, laparoscopic bariatric surgery involves making several small incisions and performing the operation by video camera. A laparoscope, the device used to capture the video, is inserted through an abdominal incision. This provides the bariatric surgeon a magnified view inside the abdomen, allowing the operation to be performed using special surgical instruments and a television monitor.

The long-term results for laparoscopic bariatric surgery and gastric bypass surgery should be similar to those for open procedures. The advantages of the laparoscopic approach include less post-operative pain, a shorter recovery period, and less extensive scarring.

The Vertical Sleeve Gastrectomy procedure (also called Sleeve Gastrectomy, Vertical Gastrectomy, Greater Curvature Gastrectomy, Parietal Gastrectomy, Gastric Reduction, Logitudinal Gastrectomy and even Vertical Gastroplasty) is performed by more and more surgeons worldwide. The earliest forms of this procedure were conceived of by Dr. Jamieson in Australia (Long Vertical Gastroplasty, Obesity Surgery 1993)- and by Dr. Johnston in England in 1996 (Magenstrasse and Mill operation- Obesity Surgery 2003). Dr Gagner in New York, refined the operation to include gastrectomy(removal of stomach) and offered it to high risk patients in 2001. Several surgeons worldwide have adopted the procedure and have offered it to low BMI and low risk patients as an alternative to laparoscopic banding of the stomach.

It generates weight loss by restricting the amount of food (and therefore calories) that can be eaten by removing 85% or more of the stomach without bypassing the intestines or causing any gastrointestinal malabsorption. It is a purely restrictive operation. It is currently indicated as an alternative to the Lap-Band? procedure for low weight individuals and as a safe option for higher weight individuals.

Anatomy

This procedure generates weight loss solely through gastric restriction (reduced stomach volume). The stomach is restricted by stapling and dividing it vertically and removing more than 85% of it. This part of the procedure is not reversible. The stomach that remains is shaped like a very slim banana and measures from 1-5 ounces (30-150cc), depending on the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while drastically reducing the volume. By comparison, in a Roux-en-Y gastric bypass, the stomach is divided, not removed, and the pylorus is excluded. The Roux-en-Y gastric bypass stomach can be reconnected (reversed) if necessary. Note that there is no intestinal bypass with this procedure, only stomach reduction. The lack of an intestinal bypass avoids potentially costly, long term complications such as marginal ulcers, Vitamin deficiencies and intestinal obstructions.

Comparison to prior Gastroplasties (stomach stapling of the 70-80s)

The Vertical Gastrectomy is a significant improvement over prior gastroplasty procedures for a number of reasons:

1) Rather than creating a pouch with silastic rings or polypropylene mesh, the VG actually resects or removes the majority of the stomach. The portion of the stomach which is removed is responsible for secreting Ghrelin, which is a hormone that is responsible for appetite and hunger. By removing this portion of the stomach rather than leaving it in-place, the level of Ghrelin is reduced to near zero, actually causing loss of or a reduction in appetite (Obesity Surgery, 15, 1024-1029, 2005). Currently, it is not known if Ghrelin levels increase again after one to two years. Patients do report that some hunger and cravings do slowly return. An excellent study by Dr. Himpens in Belgium(Obesity Surgery 2006) demonstrated that the cravings in a VSG patient 3 years after surgery are much less than in LapBand patients and this probably accounts for the superior weight loss.

2) The removed section of the stomach is actually the portion that ?stretches? the most. The long vertical tube shaped stomach that remains is the portion least likely to expand over time and it creates significant resistance to volumes of food. Remember, resistance is greatest the smaller the diameter and the longer the channel. Not only is appetite reduced, but very small amounts of food generate early and lasting satiety(fullness).

3) Finally, by not having silastic rings or mesh wrapped around the stomach, the problems which are associated with these items are eliminated (infection, obstruction, erosion, and the need for synthetic materials). An additional discussion based on choice of procedures is below.

Alternative to a Roux-en-Y Gastric Bypass

The Vertical Gastrectomy is a reasonable alternative to a Roux en Y Gastric Bypass for a number of reasons

Because there is no intestinal bypass, the risk of malabsorptive complications such as Vitamin deficiency and Protein deficiency is minimal.

There is no risk of marginal ulcer which occurs in over 2% of Roux en Y Gastric Bypass patients.

The pylorus is preserved so dumping syndrome does not occur or is minimal.

There is no intestinal obstruction since there is no intestinal bypass.

It is relatively easy to modify to an alternative procedure should weight loss be inadequate or weight regain occur.

The limited two year and 6 year weight loss data available to date is superior to current Banding and comparable to Gastric Bypass weight loss data(see Lee, Jossart, Cirangle Surgical Endoscopy 2007).

First stage of a Duodenal Switch

In 2001, Dr. Gagner performed the VSG laparoscopically in a group of very high BMI patients to try to reduce the overall risk of weight loss surgery. This was considered the ?first stage? of the Duodenal Switch procedure. Once a patient?s BMI goes above 60kg/m2, it is increasingly difficult to safely perform a Roux-en-Y gastric bypass or a Duodenal Switch using the laparoscopic approach. Morbidly obese patients who undergo the laparoscopic approach do better overall in their recovery, while minimizing pain and wound complications, when compared to patients who undergo large, open incisions for surgery (Annals of Surgery, 234 (3): pp 279-291, 2001). In addition, the Roux-en-Y gastric bypass tends to yield inadequate weight loss for patients with a BMI greater than 55kg/m2 (Annals of Surgery, 231(4): pp 524-528. The Duodenal Switch is very effective for high BMI patients but unfortunately it can also be quite risky and may be safer if done open in these patients. The solution was to ?stage? the procedure for the high BMI patients.

The VSG is a reasonable solution to this problem. It can usually be done laparoscopically even in patients weighing over 500 pounds. The stomach restriction that occurs allows these patients to lose more than 100 pounds. This dramatic weight loss allows significant improvement in health and resolution of associated medical problems such as diabetes and sleep apnea, and therefore effectively ?downstages? a patient to a lower risk group. Once the patients BMI is lower (35-40) they can return to the operating room for the ?second stage? of the procedure, which can either be the Duodenal Switch, Roux?en-Y gastric bypass or even a Lap-Band?. Current, but limited, data for this ?two stage? approach indicate adequate weight loss and fewer complications.

Vertical Gastrectomy as an only stage procedure for Low BMI patients(alternative to Lap-Band?and Gastric Bypass)

The Vertical Gastrectomy has proven to be quite safe and quite effective for individuals with a BMI in lower ranges. The following points are based on review of existing reports:

Dr. Johnston in England, 10% of his patients did fail to achieve a BMI below 35 at 5 years and these tended to be the heavier individuals. The same ones we would expect to go through a second stage as noted above. The lower BMI patients had good weight loss (Obesity Surgery 2003).

In San Francisco, Dr Lee, Jossart and Cirangle initiated this procedure for high risk and high BMI patients in 2002. The results have been very impressive. In more than 700 patients, there were no deaths, no conversions to open and a leak rate of less than 1%. The two year weight loss results are similar to the Roux en Y Gastric Bypass and the Duodenal Switch (81-86% Excess Weight Loss). Results comparing the first 216 patients are published in Surgical Endoscopy.. Earlier results were also presented at the American College of Surgeons National Meeting at a Plenary Session in October 2004 and can be found here: www.facs.org/education/gs2004/gs33lee.pdf.

Dr Himpens and colleagues in Brussels have published 3 year results comparing 40 Lap-Band? patients to 40 Laparoscopic VSG patients. The VSG patients had a superior excess weight loss of 57% compared to 41% for the Lap-Band? group (Obesity Surgery, 16, 1450-1456, 2006).

Low BMI individuals who should consider this procedure include:

Those who are concerned about the potential long term side effects of an intestinal bypass such as intestinal obstruction, ulcers, anemia, osteoporosis, Protein deficiency and vitamin deficiency.

Those who are considering a Lap-Band? but are concerned about a foreign body or worried about frequent adjustments or finding a band adjustment physician.

Those who have other medical problems that prevent them from having weight loss surgery such as anemia, Crohn?s disease, extensive prior surgery, severe asthma requiring frequent steroid use, and other complex medical conditions.

People who need to take anti-inflammatory medications may also want to consider the Vertical Gastrectomy. Unlike the gastric bypass where these medications are associated with a very high incidence of ulcer, the VSG does not seem to have the same issues. Also, Lap-Band ? patients are at higher risks for complications from NSAID use.

All surgical weight loss procedures have certain risks, complications and benefits. The ultimate result from weight loss surgery is dependent on the patients risk, how much education they receive from their surgeon, commitment to diet, establishing an exercise routine and the surgeons experience.

Advantages and Disadvantages of Vertical Sleeve Gastrectomy

Vertical Sleeve Gastrectomy Advantages

Reduces stomach capacity but tends to allow the stomach to function normally so most food items can be consumed, albeit in small amounts.

Eliminates the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin).

Dumping syndrome is avoided or minimized because the pylorus is preserved.

Minimizes the chance of an ulcer occurring.

By avoiding the intestinal bypass, almost eliminates the chance of intestinal obstruction (blockage), marginal ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency.

Very effective as a first stage procedure for high BMI patients (BMI > 55 kg/m2).

Limited results appear promising as a single stage procedure for low BMI patients (BMI 30-50 kg/m2).

Appealing option for people who are concerned about the complications of intestinal bypass procedures or who have existing anemia, Crohn?s disease and numerous other conditions that make them too high risk for intestinal bypass procedures.

Appealing option for people who are concerned about the foreign body aspect of Banding procedures.

Can be done laparoscopically in patients weighing over 500 pounds, thereby providing all the advantages of minimally invasive surgery: fewer wound and lung problems, less pain, and faster recovery.

Vertical Sleeve Gastrectomy Disadvantages

Potential for inadequate weight loss or weight regain. While this is true for all procedures, it is theoretically more possible with procedures that do not have an intestinal bypass.

Higher BMI patients will most likely need to have a second stage procedure later to help lose the rest of the weight. Remember, two stages may ultimately be safer and more effective than one operation for high BMI patients. This is an active point of discussion for bariatric surgeons.

Soft calories such as ice cream, milk shakes, etc can be absorbed and may slow weight loss.

This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur.

Because the stomach is removed, it is not reversible. It can be converted to almost any other weight loss procedure.

Considered investigational by some surgeons and insurance companies.

Much of the above information was garnered from information from Laparoscopic Associates of San Francisco. The following links provide additional important information you may want to consider in your research:

http://www.hopkinsbayview.org/bariat...ion_sleeve.pdf

http://www.iabsobesitysurgery.com/Me...eDietGuide.pdf

http://www.cornellweightlosssurgery....astrectomy.pdf

Happy Re-Birthday to Me - One Year Out, 244 Pounds Down Post-Op!

Aviator's Log Book

[mila1013 0]

thank you all for taking the time to reply, my interpretation of the denial is that it is not medically necessary because it is considered experimental, they don't actually say it but that is what they mean. gotta love bcbs.....I believe thier time is limited and that in 2011, sg will be a covered benefit but till then we have to appeal....so that is what i will do...

[Eureka-C 20]

I too was denied recently. Bc/bs CA. I was devastated. At first I decided to self pay, and I applied for a loan, but then several people on here explained how they appealed other bc/bs plans and got approved. So now I too am appealing. Luckily my loan was approved as well and I have 60 days to decide whether or not to take it. Good luck on your appeal.

[Kelkie 0]

Don't take no for an answer. I think that is what the insurance companies are after. Imagine how many people don't belong to forums like this and the others out there. They would never know they could appeal, and get the procedure they wanted. For and example, I was the only person at my pre op class that had heard of this site, and obesityhelp.com. There were 8 or 10 people there. Of course, I was the only one that had ever heard of the sleeve too. Anyway, hang in there and fight for what you want. If you don't get it on first appeal, do it again. Every state has an insurance commission of some sort that you can appeal to as well, if all else fails. The only way the insurance companies are going to quit fighting us, is if enough of us fight back and win. Come up with all the evidence you can to back up your reasons for wanting this surgery, and only this one. Find every reference out there to back up any medical issues you have that would make this a medically necessary procedure for you. Good luck!