Question:
If Ins wants to pay for (example) RNY and I want a DS, am I stuck??
If my insurance considers a DS to still be "experimental" and I don't think I want the RNY, is there any reason the surgeon can't do the DS anyway and submit to insurance with fees for the RNY (which I understand are higher anyway - so it's not like he won't receive his fee)? I don't mean to sound unethical here, but. . . I don't want to come all this way only to be stopped by some Dr miles away sitting in an insurance office telling me what I can do with my own intestines! LOL!! Any ideas?? Thanks in advance! — ChristiMNB (posted on March 12, 2001)
March 11, 2001
It is my understanding that there is someone in the surgery room who is in
charge of writing down everything the surgeon does i.e. inscision or lap,
procedure, time it took for each thing etc. so that they can bill the
insurance with the correct and accurate procedure done. That's just what
was explained to me by the Dr. office. It would be pretty hard to do a
different procedure than what was approved and have the approved procedure
show up on the billing when it wasn't the one done! Best of luck to you!
— Karen S.
March 11, 2001
HI........
I decided that wanted the DS, and when I applied to my surgeon, he KNEW I
wanted DS, but when he wrote to my insurance company, he accidentaly listed
RNY as my surgery choice. Well, his office gal called me and said
"congratulations! you are approved for the RNY procedure!" I
said 'well, thanks, but I asked for the DS'.......she said 'oops.....let me
see what's up with this.' She called back and said that the doc had made a
mistake, which he owned up to, and that they would have to REAPPLY to my
ins co! I was very apprehensive, I can tell you! It took 10 days, but I got
the call that I had been approved for the DS! whew!!! Maybe you can reapply
for the DS, and maybe you can use my doc.......Dr Dennis Smith in Marietta
GA.............they pulled off some sort of magic and made it happen...
good luck! jw
— jane W.
March 12, 2001
That would be fraudulent and I would wonder if you would really find a Dr
willing to be commit that knowing they risk losing their medical license.
— [Anonymous]
March 12, 2001
I was in the same position and lost a fight with my former insurance
company which was anHMO. However I switched to BC/BS federal and they paid
for it/ I just want to encourage you to fight for the surgery you want.
Many people win on appeal and it is worth the fight if you are sure the
BPD/DS is for you. The other thought I had was that with the surgeon I
used, there was no problem with getting approval. I don't know how they did
it but they did it! The first surgeon I consulted didn't bother fighting
insurance for me. GOod luck, I also recommend reading some of the posts on
the egroups duodenal switch group since there are many filled with how they
fought this particular denial for "experimental" surgery and won.
We all know it isn 't experimental at all!
— Jean S.
March 12, 2001
Actually, I think the fees for the DS are quite a bit higher than an RNY
and the operation is more complex. However, this being said: I would talk
with your surgeon about the insurance codes he/she uses. There is one for
'distal procedure' that I've heard *some* surgeons use to describe either a
BPD/DS OR a distal RNY. It is not fraudulent because the code is very
general and applies generally to a distal procedure. I wouldn't suggest
going into a DS surgery with prior insurance approval for an RNY. I would
definately discuss what codes are used by the surgeon and reapply for
approval if you must. It is well worth it to get exactly the procedure you
prefer and feel is right for you -- this is your new body and you will have
to live with it for the rest of your life and make the accompanying
lifestyle changes required. I wish you the best and hope everything goes
well with the insurance! I had a laparoscopic BPD/DS on January 25, 2001
and haven't regretted it for a moment! :) all the best ([email protected]),
— Teresa N.
March 17, 2001
You would need to make sure that your surgeon or PCP wrote a really
detailed letter, outlining the things I've included below. To get what you
really want, its better to be extremely specific during the approval
process- include info such as:
The Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
procedure is most effective for patients who are in the "super
morbidly obese" range (BMI higher than 50),
and provides the best chance at achieving a satisfactory percentage of
excess weight loss (%EWL) for
the patient. Dr. Douglas Hess of Bowling Green, Ohio, who initially
devised the BPD/DS procedure in
1988, published a clinical study in 1998 (Hess, et al.:
Biliopancreatic Diversion with a Duodenal Switch,
Obesity Surgery, 8, 1998; 267-282.) concluding that the BPD/DS
procedure achieves an average of
80%EWL, which occurs at 24 month post-operative and continues at a 70%
level for eight years and
beyond (By contrast, the Roux-en-Y procedure promises only 55%EWL.).
In the case of those who are
super morbidly obese, the BPD/DS procedure is warranted in order to
give one the best chance to reach
a healthy weight and to maintain the weight loss for the long-term.
Other benefits of the BPD/DS
procedure that are not found in the roux-en-y "pouch"
procedure are as follows: 1.) Retention of the natural
functionality of the reduced stomach.The partial gastrectomy leaves
the pyloric valve intact and
functioning, which means that there is no chance of post-operative
problems that can plague RNY
patients: blockages of the stoma, marginal ulcerations, narrowing of
the anastomosis requiring endoscopic
dilation, dumping syndrome. All of these problems can occur repeatedly
in RNY patients; none of these
problems can occur after the BPD/DS procedure. Furthermore, the BPD/DS
stomach is left large
enough that food can be properly digested before it is expelled into
the small intestine. This means that
BPD/DS patients may see greater protein absorption, and do see
adequate production of intrinsic
factor for vitamin B12 absorption, benefits that are not enjoyed by
RNY patients. 2.) Retention of the
duodenum in the food stream. Unlike other forms of gastric bypass, the
BPD/DS procedure does not
completely bypass the duodenum. The duodenum is where calcium,iron,
protein and zinc absorption take
place, so BPD/DS patients seldom experience dangerous deficiencies of
these nutrients. By contrast,
the RNY procedure completely bypasses the duodenum, which seems to
compromise absorption of these
nutrients to a greater degree. 3.) The BPD/DS's distal gastric bypass
provides the best long-term
weight loss potential, with little to no late regain of weight, as
noted in the above-referenced Hess report.
BPD/DS patients can reasonably expect to reach and maintain a healthy
weight, whereas other forms of
gastric bypass surgery see much greater failure rates and late regain
of weight. Just a consideration.. I think
that there is not nearly enough information about the DS on this
website. I don't know why, but there just
isn't. For more info, go to the duodenal switch information zone @
www.duodenalswitch.com. Good luck, no
matter what you choose to do!
- Liane French
— Liane F.
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