Diana S.

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I had my appointment with the Bariatric Surgeon at Kaiser's South Sacramento location today.

There was some confusion about having paperwork, and upon my confused expression they clarified that it should be in my "binder." I explained that I had never been given such a thing, and they figured out since I was asking about a revision, I apparently got to skip a lot of the initial stuff, including this mythical green binder.

I spoke with my surgeon for about 30 minutes. He asked me a lot of timing and history questions. When was my first surgery, where, when did I have my gallbladder removed, why (emergency surgery for stones), am I still taking anti-depressants, am I still taking my anti-nausea meds? How frequent are nausea and vomiting episodes? Describe your acid reflux, when did that start, how severe, etc.

Ultimately, he said that he recommended gastric bypass revision to correct my initial surgery's complications. I asked when we discuss which procedure and he said he recommended Roux-en-Y. I asked about he Duodenal Switch, citing my reasons why I was interested in that procedure. He countered with he only recommends that surgery for people with an extremely high BMI of like 60 or more. He said because of the long term nutritional deficiencies blah blah blah it's less than ideal. He also mentioned that he was less concerned about future weight loss and more concerned with doing a revision to correct the severe acid reflux symptoms.

He told me to lose 10 pounds and attend a two-hour nutrition class. Once I did that, call back and they'd schedule a psych eval. Until then, he ordered an endoscopy to look at the damage done by the years of reflux and some blood work.

I walked into my appointment with my metaphorical boxing gloves, but in the end I didn't want to turn a pleasant and easy conversation going mostly in my favor into a fight. I had studies showing that losing weight before a medically-necessary weight loss surgery had no merit and was not supported by anything anywhere. I was armed with stats on long term results of VSG, RNY and DS and studies declaring the DS as the best all around option for people in my situation. I came armed with IMR decisions finding that DS for patients with a BMI greater than 50 had no better or worse results than in people with BMIs under 50... and in the end I didn't pull out any of those points. Did I chicken out or was discretion the better part of valor here?

I am going to research RNY vs. DS more in-depth, but I really feel DS is the right option for me. At what point do I start my fight for the procedure I actually want, without throwing down too early and they just take away what they've already offered to do?

I compiled/wrote this letter (with a LOT of help and copy/pasting from http://www.obesityhelp.com/content/letterofmedicalnecessity.html which was an amazing resource!) as something to hand to my bariatric surgeon at our initial consult tomorrow afternoon. It includes a LOT of verbiage from the link posted, and then some info gleaned from BariatricFacts.org (http://bariatricfacts.org/threads/revisions-does-the-patient-fail-the-procedure-or-does-the-procedure-fail-the-patient.245/) and some cases from the DMHC Independent Medical Review site (http://wpso.dmhc.ca.gov/imr/). I also looked up some long-term results studies in order to make a few graphs plotting out my personal weight loss progression, and how that compares to others in my shoes. 

I hope with everything included that it is a strong letter for both my surgeon, and for any appeals that I may have to tackle. I'm throwing it out there as an example if anyone is interested, for any feedback for last minute edits (since my appointment is TOMORROW!), and for general putting it out there in the universe.

Wish me luck!

 

Diana's Letter of Medical Necessity

http://georgetownfiredepartment.com/DJS/WLS%20Letter.pdf

 

I JUST called up Kaiser Member Services and said I was looking for more information on their Bariatric Coverage. My Evidence of Coverage Booklet merely says:

"Bariatric Surgery We cover hospital inpatient care related to bariatric surgical procedures (including room and board, imaging, laboratory, special procedures, and Plan Physician Services) when performed to treat obesity by modification of the gastrointestinal tract to reduce nutrient intake and absorption."  ... it has more verbiage on transportation reimbursement to/from facilities relating to bariatric surgery than specifics, types of surgeries covered, exceptions or whatever other details. It doesn't even specify revisions one way or another.

So I asked the representative what specifically was covered. When she asked me what I was looking for, knowing that DS might be a trigger-to-not-help-you-anymore, I evaded and said I was looking into several different kinds. She listed LSDGB, RYGB, and Sleeve with DS (!!!!!). I then asked if the coverage specified anything about revisions, and she said "repeat bariatric surgeries" was included in my coverage. Both the DS and the revision aspect are covered when deemed "medically necessary" and upon completion of the Preparatory Program. 

I did also ask if there was a Kaiser DS surgeon or if that's contracted out, and she was a little fuzzy on the answer, but said if Kaiser can't perform the surgery recommended, that they would contract it out to someone who does. I'm assuming that would be Dr. Rabkin.

The "medically necessary" part may be my river to cross, but it sounds like they're mostly on-board. I wonder if because my Kaiser Insurance is through CalPERS (I'm a County Employee) that makes a huge difference?

Crossing all my fingers for a happy appointment on December 1st!

In Dec 2005 I had my Vertical Gastrectomy with Dr. Feng at LAPSF. I remember having lost 30 lbs in the first 30 days! I went from 340 to the lower 200s in two years, and we threw a huge party when I could get into size 30 women's jeans. That was the first time I'd worn women's jeans since mid high school. Oct 2007 I had an abdominoplasty and breast lift to put everything back where it needed to be, and after removing 15 lbs of skin, my old photos remind me I was something like 205 lbs. 

After losing both my parents, and surviving an abusive boyfriend that eventually turned into my many-year-long stalking nightmare, I regained to about 260 and stayed there for years. Two years ago I had my son, and my end of pregnancy weight was 280. Since then I've been about the same and weighed in at 287 the other day. 

Apparently in 2009 I was looking into having a revision to the duodenal switch, but life happened and insurance didn't. I am revisiting the issue now and want to document my progress thus far. 

On Monday the 14th I started scouring my insurance documents to see if they might consider covering weight loss surgery of some kind. I have CalPERS Kaiser, and they say little other than yes they do cover it. I immediately requested an appointment with my PCP and got in that same day. He barely seemed surprised and asked only a few questions, then submitted the referral to the Kaiser Bariatrics Center. He also referred me to the Kaiser Sleep Center.

My first appointment with the Sleep Center gave me a wonky device I wore overnight to monitor my sleep pattern and see if I qualified for the next step. My results showed Moderate Apnea, and I'm scheduled for whatever awaits me regarding Phase Two, next Wednesday the 23rd.

Today, the Bariatrics Center called me and scheduled me for an appointment on December 1st. We shall see how that goes. 

In the mean time, with a million questions and a mountain of anxiety, I'm scouring the web and OH's forums for answers, and so far I've learned that the pre-surgery weight loss requirement is garbage and easily fought if they throw that at me. Class series and orientations are not mandatory, and while are a good idea for some, I'm the type that was faithful in execution of my new lifestyle, went through all that education for my first surgery, have researched the heck out of any new information, and feel those classes hold nothing of value for me. Psych evals may be necessary, and I'm fine with that. Oodles of pre-op testing and blood work is almost a certainty, and I'm fine with that too. I wonder how this will go and if the timeline can be fairly swift. I was a self-pay for my first surgery and that was the only way to get people to respond to me in a timely manner. 

My list of things to bring up with the Bariatric Center surgeon:

inadequate weight loss from first surgery

returning sleep apnea 

was borderline gestational diabetic whilst pregnant and concerned that's the future of my current state 

family history of hypertension - may have contributed to my father'a sudden passing

severe and chronic acid reflux, controlled only through medication - maybe GERD?

returning pain in joints and feet

frequent vomiting and nausea - so much so that my husband was certain I was pregnant again!

Anyway, I'm hoping for the best. Until I reach a hurdle, I'm using this to help vent some anxiety and organize my thoughts. 

So my VG surgery was three and a half years ago. My top weight was 342, and my current weight is 265. After my plastic surgery about a year and a half ago, I bottomed out at 205 but then I had a lot of crap fly at me in my personal life, including a major change in lifestyle, abusive soon to be ex husband and my mother passed on from cancer. Needless to say that I've delt poorly with these recent events, and it doesn't help a whole lot that I work in an office, an hour and a half from my home by car. I am always sitting except for my hour or so of exercise three times a week... not even nearly enough but what else can I work into my schedule? Bah

Anyway, I have an amazing position in an amazing company that offers me pretty good benefits. I've heard that Aetna is great, and that Aetna sucks, but Aetna is who I have and they seem to be approving the kinds of things I want.

I originally had my VG with Dr. Feng, previously with Laparoscopic Associates of San Francisco, and loved my experience so much that I've gone back to LAPSF to have my revision with another of their doctors. I met with Dr. Cirangle Friday 5/29 and we chatted about getting my VG revised to a Duodenal Switch. Aetna seems to be difficult but there's a good chance that they'll approve this, and Dr. Cirangle gave me a list of tests and Rxs to get the ball rolling. I need to schedule my cardiogram and bloodwork and all that, but it seems that a DS is in my near future!

Oh my god... I did it. I'm home and bandaged, and full of pain meds. Even with my prescribed Percocet, the only times I am pain-free are when I am very still or sleeping (it's the small victories). I rediscover how to get up every five hours (and I say rediscover because I never do it the same way twice) so that I can relieve myself, empty my drains and record what they've collected, take my pain meds and see briefly either to my bird's or my own nutritional needs. Then I very very very carefully put myself back into my bed, reposition my support pillows and zonk out.

It's funny. I really haven't looked at myself, nor do I yet care to. I am in that place where upon looking at my stitches, I want to feint. I very nearly did yesterday. Gayatri was taking me from the hospital to Dr. Chang's office so that they could change my bandages and let me know what to do with them and when, when the nurse (Mary) took the binding off that was around my middle. I guess what happened was that without the compression of the binding, all the blood in my body rushed there and out of my head. I became painfully dizzy and light-headed, and a static-like whiteness filled my field of vision. They had me lay down until it passed and then I felt much better.

So while I was still in the hospital, I was walking better and much sooner than they expected, and apparently I have quite a bit more sensation in my incisions than expected. They told me time and time again to expect numbness that would eventually come back, and here I am hyper-sensitive!

I'm happy that I am able to mobilize enough to take care of my needs, but I'm conflicted in the fact that it's pretty lonely here. Like, I don't really want anyone to see me walking around all hunched over because I'd rather die than stand up straight, but at the same time I crave the company. It will be nice to go to Grass Valley and see my family and pseudo-family, but I'd just as soon skip the 150 mile ride. :P

At least it's all done and I'm healing! Yay!

I had my two-week pre-op visit today (the 18th). I'll be having a pretty extensive abdominoplasty/tummy-tuck, mastopexy/breast lift and augmentation, mostly because the lift will minimize my breasts into non-existance.

The nurse and I went over a billion details, things I can expect, about the drains, about the pain, about the scars, about the implants, about the things I'll need, about the hospital stay, about the down-time. She took some x-rated 'before' pics of me (that I might post later), and then I waited to talk to my surgeon. When Dr. Chang came into the room, she came with all different sizes of implants. We put on a stretchy-bra and played with different sizes. We finally decided on the 300cc silicone implants, and she sent me off to do paperwork.

I guess silicone implants have recently been okayed for everyone by the FDA, even though they have been used for years... just for certain circumstances. There are also myths about silicone implants that have recently been completely disproven. Anyway, since this free-for-all silicone implant thing is fairly new, I was asked to be a part of a 10-year study. I signed up and as a perk, I get this interesting lifetime warantee. I didn't realize such things existed! Haha :)

Anyway, so I will be pretty much completely worthless for three weeks. I am directed to be pretty much stuck at home, the most activity to be had will be shuffling around the house hugging a pillow for extra support. I will fill my antibiotic and pain med prescriptions within the next couple days and will be stocking up on liquids, food, extra pillows, preparing clean laundry and buying movies and books to keep me company. I will need a ride to and from the hospital in SF, and they asked me if I'll have someone with me overnight, and as of yet this/these position/s are unfilled. I'm sure I can get a friend or family member to help me in this way, but I'm not entirely sure how to ask, since I'm sure anyone I do ask will say yes... but what I really want is someone who genuinely wants to do such a thing. How does one figure that out?

So yeah. I'm totally amped and the time is officially winding down to surgery. My friend told me I should bring a mummy mask with me, since I'll be all in bandages and it's Halloween! Really cute :P

Until next time, my pretties...

So I have a doctor and a date!

I talked to many many places in the Bay Area about their practice, I've explored their respective websites, I've reviewed a bazillion before and after pictures... in essence, I've done my homework. I called and made a colsultation appointment with my favored place, and they were able to work me in right away. I went in and met the staff and doctors yesterday and I adore the facility and people! This is their website and my doctor will be Dr. Carolyn Chang.

http://www.womensplasticsurgery.com/

My surgery date is Halloween :) yeah yeah... but it's October 31st and I will be getting a T-shaped Tummy Tuck, a Breast Lift and Augmentation. I will have an appointment two weeks prior to surgery to determine details and... well I'm not a hundred percent sure. My procedure will run about $20k but I don't have to deal with any insurance company bullsh!t.

So I will update again when I know more :) !

Hey OH Community. So it's been a few years and I've been the same weight for 9+ months. My body and my life are completely different, but now I have a completely different issue: skin. I knew this was coming, and I think now is the time to get all that extra skin removed. I have the cash, now I just need to find the doctor and the procedures. I will update with my progress!

Diana