Going forward from part 1 (VSG) and on to DS

momyshaver
on 12/5/17 4:25 pm
VSG on 06/28/17

Hi,

I was wondering if anyone had any feedback. I had VSG in June and I am strongly considering proceeding to the second part of the surgery, which is the DS. However, my BMI is lower now that I have lost weight. Is insurance likely to cover part 2 (the actual DS)?

califsleevin
on 12/5/17 9:23 pm - CA

The conundrum that I discussed with my surgeon on this issue when I was considering the VSG/DS question is that while the second stage DS follow on works best then done early, before any substantial regain occurs (so kudos to you for considering it now, rather than later!) the insurance doesn't usually cover it unless you are still above the typical BMI 35/40 threshold, or have regained back up to that level (where the revision doesn't work as well.) Insurance policies can differ, but that's the general practice, unless things were set up with them from the beginning to do a planned two stage DS. Usually, the only other times revisions are covered with a low (or normally non-qualifying) BMI is if the revision is to correct a complication from the original covered surgery.

So, my reading of it is that it doesn't look good for coverage, but you should check with your specific insurer to see what their actual policy is on such matters.

Good luck in this....

1st support group/seminar - 8/03 (has it been that long?)  

Wife's DS - 5/05 w Dr. Robert Rabkin   VSG on 5/9/11 by Dr. John Rabkin

 

momyshaver
on 12/6/17 7:49 am
VSG on 06/28/17
On December 6, 2017 at 5:23 AM Pacific Time, califsleevin wrote:

The conundrum that I discussed with my surgeon on this issue when I was considering the VSG/DS question is that while the second stage DS follow on works best then done early, before any substantial regain occurs (so kudos to you for considering it now, rather than later!) the insurance doesn't usually cover it unless you are still above the typical BMI 35/40 threshold, or have regained back up to that level (where the revision doesn't work as well.) Insurance policies can differ, but that's the general practice, unless things were set up with them from the beginning to do a planned two stage DS. Usually, the only other times revisions are covered with a low (or normally non-qualifying) BMI is if the revision is to correct a complication from the original covered surgery.

So, my reading of it is that it doesn't look good for coverage, but you should check with your specific insurer to see what their actual policy is on such matters.

Good luck in this....

Thank you for responding. There is only 1 surgeon in my state who even does DS and to get an appointment with them I need a referral from my Dr. Now, I had a referral there but it was only good for 90 days and I went elsewhere for my gastric sleeve, (that surgeon does not do DS either). I am hoping that since I have health issues that would be negatively impacted by weight regain and that since DS has the highest success rate with weight loss and keeping weight off, that this bariatric center will help me with the insurance portion. I know they are experts at that sort of thing. I just want to look at the long view and be healthy. Of course there are many people who are saying that I should not consider the DS because of the risk; however, I consider the medications I take, of which obesity makes worse, to be more of a negative, (which is why I went out of area to start the weight loss process by having the sleeve done. I knew if I stayed in my area I was looking at least a year and many hoops which would be difficult to jump through as a caretaker of a disabled toddler). I just want to be healthy. I really hope whatever is best works out. I will update.

Janet P.
on 12/6/17 10:17 am
On December 6, 2017 at 3:49 PM Pacific Time, momyshaver wrote:
On December 6, 2017 at 5:23 AM Pacific Time, califsleevin wrote:

The conundrum that I discussed with my surgeon on this issue when I was considering the VSG/DS question is that while the second stage DS follow on works best then done early, before any substantial regain occurs (so kudos to you for considering it now, rather than later!) the insurance doesn't usually cover it unless you are still above the typical BMI 35/40 threshold, or have regained back up to that level (where the revision doesn't work as well.) Insurance policies can differ, but that's the general practice, unless things were set up with them from the beginning to do a planned two stage DS. Usually, the only other times revisions are covered with a low (or normally non-qualifying) BMI is if the revision is to correct a complication from the original covered surgery.

So, my reading of it is that it doesn't look good for coverage, but you should check with your specific insurer to see what their actual policy is on such matters.

Good luck in this....

Thank you for responding. There is only 1 surgeon in my state who even does DS and to get an appointment with them I need a referral from my Dr. Now, I had a referral there but it was only good for 90 days and I went elsewhere for my gastric sleeve, (that surgeon does not do DS either). I am hoping that since I have health issues that would be negatively impacted by weight regain and that since DS has the highest success rate with weight loss and keeping weight off, that this bariatric center will help me with the insurance portion. I know they are experts at that sort of thing. I just want to look at the long view and be healthy. Of course there are many people who are saying that I should not consider the DS because of the risk; however, I consider the medications I take, of which obesity makes worse, to be more of a negative, (which is why I went out of area to start the weight loss process by having the sleeve done. I knew if I stayed in my area I was looking at least a year and many hoops which would be difficult to jump through as a caretaker of a disabled toddler). I just want to be healthy. I really hope whatever is best works out. I will update.

Was there a specific reason you chose not to have the DS in June when you opted for the VSG? You mention in your response that many people say that you shouldn't consider the DS because of the risk. What risk are you referring to? I'm just trying to understand why you have decided on the switch part when you're only 6 months into the VSG.

Janet in Reston
DS 2/25/03
Hazem Elariny
-175
momyshaver
on 12/7/17 3:08 am
VSG on 06/28/17

The surgeon I went to did not offer DS as a procedure. There is only 1 surgeon in my entire state who does the surgery. I was self pay in June and traveled to have the sleeve done. The risk that my surgeon stated for not doing DS was the long term malabsortive issues with DS and that it was riskier overall for bleeding etc. I did not feel it was out of the norm to do the sleeve first in order to improve overall health and lose weight before the second part of the entire DS. That was how the stand alone gastric sleeve was "discovered", correct? However, DS is the process that has the greatest chance of long term weight loss and maintenance and that is what I need for my long term health issues

PeteA
on 12/7/17 5:35 am - Parma, OH
DS on 04/15/13

I see you mentioned you were self pay on the VSG do I have that right? If so you are probably in a better position to get insurance since a second WLS is rarely covered. A lot will depend on your insurance just don't let it go if you get an initial rejection. A lot of times they seem to just want to put you through hoops to get the approval.

Usually, people that do a 2 step through insurance make sure that insurance understands that they are getting a DS but usually for health reasons need to split the surgery into 2.

Personally, I think getting the switch part is your best chance of keeping the weight off long term. Sure, a lot of people can be successful with the VSG but we see a lot of stories for regain too.

Good for you to be thinking about your options and good luck.

Pete

 HW  552    CW  229  SW 464 4/15/13 - Lap DS by Dr. Philip  Schauer - Cleveland Clinic.

    

    

momyshaver
on 12/7/17 5:39 am
VSG on 06/28/17

Thank you for your response. I have my medical records from my gastric sleeve surgery and I am hoping that the bariatric surgeon who does DS closer to home in my state can understand and justify also why keeping the weight off will save the insurance company money in the long run

Valerie G.
on 12/8/17 12:59 pm - Northwest Mountains, GA

If you were pre-approved for a 2 part DS ,then yes. If not, then you will probably need to qualify for WLS all over again, which would be a BMI of 40, or 35 with comorbities.

Valerie
11 years post op DS 
There is room on this earth for all of God's creatures..next to the mashed potatoes

×