How to get over the next hurdle?

I saw my nutitionist for the first of 6 visits today and during our conversation she asked what surgery I was interested in. I told her The D S and we talked about the reasons why I wanted that over the RNY. When I got home she called and said my insurance will not cover the DS and that the only surgeries they would cover would be RNY or Lapband. I told her that was not my understanding when I talked to them a couple weeks ago and that I would call them againand check it out. So I called and this lady told me they actually only cover the RNY unless the surgeon finds it medically necessary. If he finds it medically necessary they will pay for what ever surgery he does. So has anyone dealt ith this and how should I go about getting the surgeon to make it medically necessary?

First question does the surgeon that you are considering, really do the DS?  There are lots of bait and don't switch doctors.  Say they do the DS, but then insurance only pays for RNY.  Check out DSfacts.com and see if there is a DS surgeon in your area.

For me I wanted that 98% chance to cure my diabetes not just resolve it by losing weight. 

My guess is that the doc you are seeing doesn't do the DS, and therefore isn't about to find it medically necessary for you. Your next step is to get yourself to a surgeon who does the DS and determine that this surgeon will support your decision and tell your insurer that the Ds is in fact medically necessary for you.

For the nut to tell you that your insurer "doesn't cover" the DS, assumng that's what she said, was somewhat misleading and worrisome. Perhaps she was really told this, or perhaps it was a self-serving statement to get you to pick an operation the surgeon she works for does. I would be very cautious.

Larra

I live in WI. No surgeons listed from our state on DSfacts.com. He does have it listed on his web site and also told me during the seminar that he does. He said he has only done a dozen of them and that not many people ask for that surgery. Dr Thomas Chua is his name and he is out of Milwaukee

Any suggestions on reason to give to my doctor on why it should be medically necassary? Like the use of NSAID?

In my very humble opinion... I would start looking for a vetted DS surgeon.  Even if you have to travel to get it done.  This surgery is complicated enough without adding a relative newbee for a surgeon to your list of burdens to carry right now.

When you find the right surgeon, they will have all the answers and codes to communicate with your health insurance company to get approvals for your surgery.  You should not be having to convince your doctor that this is the right surgery for you.  You need to find a doctor who can determine that you are a good fit for a DS and they do all the heavy lifting.

The major reason I chose the DS from all the others is my personal behaviors and eating patterns.  I knew that restriction was not going to hold me past a couple of years.  I would eat my way around it.   After all, stats show that the RNY works for only 50% of the patients over time (meaning half of the RNY patients regain all or a majority of the weight back) - so I knew I would be in front of this line.  I have to have the mal-absorbtion to keep the weight off over time.  I did not care what my sleeve size was - or if I even got a sleeve done. Heck, I know how to shrink my stomach.   What I wanted/needed was the short common channel - because my body can squeeze a calorie out of the moisture in the air.

Yes, being able to take NSAIDS is great.   So is not dumping.  I like the stats also: DS people lose 75-80% of excess weight.  RNY people lose 50%.  A higher percentage of DSers keep the weight off than RNY people

Good luck with what ever method you choose.

NSAIDs are a very good reason, as a pouch doesn't handle NSAIDs well.  But, a fully working stomach with the DS does.  Quality of life, best chance for losing the weight and keeping it off, and the 98-99% chance of curing diabetes.

As for your surgeon, who did he proctor under?  Most DS surgeons, proctor with another DS surgeon when learning how to do the procedure.  You may have to travel if you want the DS.

Jim -

At the very least, consider getting a second opinion on what surgery would be best for you.

If possible, try visiting a practice that does all types of bariatric surgery.  That way (in theory at least), they won't push one surgery over another.  I felt very confident that my surgery program did just that for me and recommended what was best.  The insurance issues, while extremely important, should be secondary.  Your safety, health, and eventual success need to come first.

Best of luck!