Having Band Removed Insurance question.

lessISmore · July 13, 2006

Hi all, it has been a while since I have posted. Briefly, my situation is that my band slipped in June of 2005, Dr. Elariny in Northern VA wanted to do a duodenal switch without even investigating fixing the band. I finally switched doctors to Dr. Schweitzer at Johns Hopkins. After a few tests he found my esophagus is contracted (I think that is what it is). It is a problem commonly associated with the lap band and he said I need to have the band removed.

He has suggested a weight loss surgery that is basically the first part of the duodenal switch where the stomach is cut smaller and a large “sleeve” like band is placed around the stomach. The rest of the digestive system is left alone. It is called Laparoscopic Sleeve Gastrectomy.

I have gained 70 pounds in the last year (about one to two pounds a week). I am constantly hungry, I even wake up in the middle of the night ravenous. I want and need the WLS but now insurance has said I have to go through the whole evaluation I went through when I got the band three years ago. My BMI is too low to automatically approve me. I need to list and document a year of diets that have failed, I have to spend at least 3 months with a nutritionist (documented). I need to have another Dr besides Dr. Schweitzer say that the Lap-band has failed and why. And the list goes on and on before they will even consider approving me for the surgery.

I feel like I have already proved that I need WLS three years ago when I went through the first evaluation. The fact that I have gained 70 pounds over the past year should prove that I still need some sort of outside control to lose weight. Do I have to get obese again to bring up my BMI? I am almost 50 and that is really, really a horrible idea to me. I could very well die just trying to prove to the insurance company that I need the surgery. I have a 5 year old, I cannot risk being obese again.

Has anyone else out there had this problem?

Help!!:cry

GeezerSue · July 13, 2006

I've had most of them...at least the band and esophagus parts. But I regained my way back to MO. So, I had problems secondary to the band, which meant that the band had to go...and I qualified for wls. (My band had been self-pay in Mexico.)

I think that you need to at least find out about the entire appeal process available to you...how it works and how to make it work to your advantage.

rachele · July 14, 2006

Dr. Schweitzer is MY doctor, and he SOO rocks. You have got the best.

He did my Lap Band in 2002, I had scar tissue that blocked the tubing and rendered the band useless. Throughout a pregnancy and a short period of time afterward, I regained much of the original 110 (give or take) that I had lost. He gave me the choice of scraping out the scar tissue and starting again. (I feel for you here, because it is devastating beyond devastating to lose it and then regain it) I requested a DS (Duodenal Switch). He was ok with that since my bmi was back up to 40something.

Honestly, I think if I hadn't had the problem with the scar tissue that I still wouldn't have been, long term, successful with my band. I am totally an addict, I have never been successful with a diet, and for real, I had to diet with the band, especially after I lost that large portion of weight in the beginning. (Some people may disagree with me, but this was MY experience, and mine alone) The bottom line is for me, I NEED the malabsorption. The DS also removes part of the stomach where the "hunger hormone" Ghrelin (sp?) is produced. This has done alot for me. A restrictive proceedure, which is what the band and the sleeve are, just did not suit my needs.

I couldn't eat hardly anything, especially anything that could be considered healthy such as chicken, vegtables and fruit unless it was slathered in sauce (lube!). I was miserable. This is how it went. I gained weight because I ate soft foods because I had a fill we couldn't get out. The soft foods caused more weight gain, which caused the band to be tighter, which caused more soft foods.....you see what I mean?

I had UHC, and they approved it without any problems at all. The removal and revision, I mean. Who is your insurance company? I know my primary care doctor had to write a letter recommending the removal, maybe that is what your insurance company means? I had my primary care doctor fax a copy of the letter to Debbie, who was handling all of Dr. Schweitzers stuff, and she faxed them all in together.

lessISmore · July 14, 2006

Thank you GeezerSue and Rachele.

I agree Rachele, Dr. Schweitzer does ROCK! He is really the best I have had so far. I did have my general practitioner fax Dr. a letter supporting my surgery (to have the band taken out and have the gastric sleeve put in at the same time) and Debbie faxed it to the insurance company (Principle Life). I called them yesterday and they did not get the fax. So I got the number again and called Debbie who faxed it again yesterday (the number to fax to had changed). So I still have to wait until they deny me again before I can appeal the decision.

When I talked to the insurance rep yesterday he said that now I had to show three years of morbid obesity with recoded attempts at failed diets and a nutritionist guidance for at lest three months! I am just really desperate! Both Pat and Debbie at Dr. Schweitzer’s office have been both supportive and helpful. I am just discouraged at how slow this whole process is. If Dr. Elariny had not spent 4 months after the initial 2 months I took to heal trying to convince me to do a self-pay duodenal switch and if I had just gone to Dr. Schweitzer after the first time Dr. Elariny tried to talk me into the surgery I would be months ahead of where I am now.

It is my fault really. At least I knew enough to seek another opinion when I did not feel comfortable with Dr. Elariny’s recommendations. It took me a while but I did finally put my foot down and say “no” to him and his insistence that the other surgery was the only way to go.

Sorry for the long post but it feels good to “talk” about it with others who have some idea what I am going through.

Thank you, thank you, thank you!!!!

Bonnie

Start 300 lb

Band slip 160 lb

today 235

rachele · July 14, 2006

Wow. Look at your numbers. You did great! I think (not that I am an expert in no way) that the sleeve may be just the thing for you. Seems like you rock the restrictive surgery route.

Another girl on another board is having the opposite problem of you. She wants the DS, and her doctor wants her to get the sleeve. BUT, she didn't have the success you had with the band.

It is such a tough, tough situation you are in. Screwed no matter where you turn. It's like the damn insurance company wants you to be M.O. again before they put you through the ringer AGAIN. Don't give up. Keep appealing. Sue has a bit of knowledge when it comes to that, I'm sure she'd be more than happy to help you out. Right, Sue? :eek:

taylorrae9 · July 15, 2006

Hello lessismore,

I am in the same process as you. I went to the MD today and after trying for 18 months to loose wieght we desided I should have a revision. Something we have been talking about for a year although he wishes I would keep trying to make the band work. I have a choice and the revision is already approved.

I am just torn about my options. I asked for the Duodenal Switch and he thought I would have a lot of problems... long term and suggested the Gastric bypass and then we talked about the sleeve. I am scheduled for August 15 at 7 am. I am afraid if I do not do the bypass piece I might regret it. Yet, I weigh 242 most days and he thinks no matter what I do I will loose 60-70 pounds which is okay for me.

It was hard today because I wanted him to take the Fluid out of the band so I could eat but the last time we did that I gained 20 pounds. He would like me to keep trying and talked about only taking a small amount of saline out and that we might hit the magic spot. I agreed because unless I wanted the band removed and no more wls he was clear loosing more weight would be ideal and that gaining so was not an option.

I ended up falling apart after the appointment. I don't cry often but today I did. I am so disappointed that the band did not work for me and that I have struggled so hard with only lost 60 pounds. Now, I will face another surgery. I am torn about which one. I am so tired and I feel so discouraged most of the time but I will move forward. The doctor suggested I might be consuming more calories than I think. I offered to write it all down and let him take a look next time we meet. It seems the story of my life is someone saying are you sure your not eating more...are you exercising.... He was nice about it but it was hard for me.

So for me I am facing surgery a week before school starts for my two girls and then my son goes a week later to preschool. The timing is a bit off but I am really tired of not eating and not loosing weight. We were going to put it off until they were settled in but not eating is really shoving me over the edge.

If I am going to suffer I should at least be loosing weight. It is so funny because I am doing all this so I can get a hip replacement. I just want to feel better and be better for my family. I want a better quailty of life.

Take care,

Taylorrae9

GeezerSue · July 17, 2006

Melanie...let me rant for a moment about RnY. It is--after the first year or so--mostly a restrictive surgery, just like the band. I decided that since the most I ever lost with the band was about 35% of my excess weight, it would be the very definition of insanity (FOR ME) to do essentially the same thing and expect different results.

That's why I went for DS (FOR ME).

I know that Jossart is listed as a DS surgeon in SF, but so is Kaufmann in LA. Yet, Kaufmann essentially ignored my requests for the DS (and was a rude and arrogrant little twit in addition.) He said that banded with a BMI of 48, I "wasn't heavy enough" for the DS and tried to get me on board for the RnY.

I am SO glad I went elsewhere.

I am seven months post-op...I'm a "slow loser" because I'm not particularly compliant (revisons can be that way since we go into surgery #2 with attitude) and I'm down somewhere around 86 pounds, WHICH IS ABOUT 60% OF MY EXCESS WEIGHT!! I was back into 2X's and 3X's pre-op. I'm losing all over, but my belly was the biggest, so right now I fit best in maternity pants for the extra room at the waist. I wore a pair of Gap size 14 maternity shorts to go to an activity at the beach last week. So I have CLOSE TO a size 14 ass and thighs.

Good luck on YOUR decision, but don't go for any surgery YOU are not convinced is right for YOU.

taylorrae9 · July 18, 2006

Hi GeezerSue,

I am not sure what to do really. It seems like I need to do something but since he reduces ne by .75 I am able to eat some more and feel like I can wait to make the right decision. My daughter made a comment that she could se I was eating again and was happy for me. It is wierd because the kids seem si self absorbed I thought they did not really notice. I am most likely going to wait till the kids are in school now that I can eat some. It iwll give me some more time to make the right choice. So thanks for the idea. I did not know the RNY was similiar to the band. I am also checking into medifast as something to do at the same time to see if I can loose some that way.lets keep in touch. Take care

GeezerSue · July 18, 2006

... It is wierd because the kids seem si self absorbed I thought they did not really notice.
...I did not know the RNY was similiar to the band.

After we went out to dinner, a friend's husband (a rather quiet 70-year-old man) asked her if I wasn't starving since I couldn't eat anything. I was surprised HE noticed.

Ther RnY DOES have malabsorption...that's why the dumping. But it primarily restrictive in nature. So it has more in common with the band than one might imagine. Even similar "end results."

Anthony · July 19, 2006

Ther RnY DOES have malabsorption...that's why the dumping. But it primarily restrictive in nature. So it has more in common with the band than one might imagine. Even similar "end results."

Actually, I believe that dumping is a result of concentrated/undigested food reaching the intestines too quickly.

Example: I can experience dumping with my Vertical [sleeve] Gastrectomy, yet I have no malabsorptive component.