X-Post: Question VSG vs DS, Insurance issues, what would you do?

My insurance is denying my hubby's request for a DS because his BMI is not greater than 50. 

In our opinion the only other option is the VSG.   The band is not an option, as I had a failed band experience and don't recommend them, and no RNY as I worked at a bariatric clinic and know way too much about the "behind the scenes" things with that one.

When I needed a revision from the band, I wanted the VSG.  Did the research and fought the insurance company and was denied at every turn for it.  Yet they approved me for the Rny, and then when requested for the DS.  I did the DS at a BMI of 53.  Siince that time they have started approving the sleeve.

Well, I love my DS.   I know I basically have the VSG stomach with the extra bonus of malabsorbtion.  The stomach part is heaven when compared to the band, so I have no problem recommending that.  But, I know how my hubby likes to eat and wonder if the restriction alone will be "good enough" for him.

My concerns are that he will not have adequate weight loss, and that it will stretch out and he will regain.  

So now we have to decide to either quit, or "settle" for the VSG.  I know I am posting this on both the boards, and I know that we are probably biased because of the choice we made, but if you had ONLY the choice of VSG or nothing... would you do it?  And if you did have the VSG how do you lose weight and keep it off? (Low fat, low carb, low cal?)

I am so spoiled now with my DS, and I know how my DH likes to eat.  It just does not seem that the VSG would be enough for him.  He is wondering the same thing, so we are looking for some hopeful/helpful information.

Thank you in advance and please remember, I do not want to be flamed for the questions, I honestly need advice/help.

Thank you!

Poodles,

Am I missing something in your post?  You say you fought your insurance company for your revision but now you sound like fighting is not an option for hubby. People have fought the < 50 BMI denial and won.. Please post the specifics of your insurance (company, policy-type, where administered) so those with successful appeal knowledge and/or experience can assist you...

this is my opinion only, since i am a 4x revision, I would not settle for a surgery I didn't want, and I would exhaust all avenues, and seek all avaialble remedies.  due to complications the DS was my only choice so you bet I fought for it.  this is really a personal choice.  I also think that if the denial reason is bmi is not 50 well BS to that, as you can produce peer reviewed journals to show the value of the DS as a surgical option in which the 50 bmi is ridiculous.   I had the DS in the low 30's, others have had the DS in the 20's.  it is worth fighting for, don't settle.  appeal the denial.... because it is not fun being on the revision table.  wishing you well....

What operation does your husband want? If he wants the DS, appeal, appeal, appeal. Many people have successfully fought the bmi 50 (some insurers even say 60!) thing successfully. There is no medical justification for it, and it doesn't conform with the NIH criteria, Medicare, etc etc. If someone meets the NIH criteria for wls, they qualify for the DS.
    Of course, your insurer won't see it that way, but that's what appeals are for. I share your concerns about the sleeve stretching out over time - longterm results for the sleeve are still unknown, though we do know that unless the sleeve is made very narrow, even the intermediate results will show weight regain by about 4-5 years post-op. And shortterm results are much like RNY, which is to say, not as good as the DS for either weight loss OR resolution of comorbidities.
     MO is a chronic, lifelong medical problem. There is IMHO no rationale for an operation that only works shortterm, you need something that will continue working for the rest of your life.

Larra

I say, fight for what you want. It's so worth it! Took me 2 years and here I am 10 ,months post op. I know the Sleeve alone would NOT have worked for me in the long term!! Good luck!


Ruby

FEP BCBS does cover DS. You don't have to be over 50 BMI. BCBS is confussed. They are probably looking at their local policy's which do say something about the 50 +BMI  for DS but it does not restrict lower BMI from having it and the FEP Plan doesn't even mention the DS and 50 BMI in it at all.

Did you request this 'Federal' policy to be sent to you in writing? Because i don't think it excists. My insurance guru at my surgeons office was confussed as well because BCBS didn't have their crap together. FIGHT this! Believe me I am holding FEP policy in hand and it says nothing about this at all! I am calling my insurance tonight and asking for a manager and making them sign the Federal Policy and send it to me for proof. I have had several reps tell me just to follow the policy I have. I am having this same battle, stay strong and stick it to them!

I refuse to get anything other than the DS!

Here is a link to Fep BCBS 2011 Policy. Just go to this sight and scroll down and download the BCBS Service Benefit Plan.


http://www.fepblue.org/benefitplans/index.jsp

I bet if you looked up the BCBS policy in the state your having your surgery, it will say something about 50 + BMI but that is the local policy. They get it confussed with Fep policy a lot!

This is what I have found so far but each battle is different. So I could be mistaken but ... I don't think I am. I hope this helps.

I would exhaust the appeals process first.

Here is a link to some atricles that might help you out......
http://www.dsfacts.com/articles.html





GOOD LUCK!!!!!  You and your husband should fight for the DS!!!!!
-Jamie