DrHekier

About 2 weeks ago I attended a Lap Band symposium and the change for Aetna was mentioned. Apparently it just took place a few weeks ago. My understanding is that Lap Band and Gastric Bypass are now on equal footing as far as Aetna is concerned. In the past Aetna had extra criteria required for patients who wanted to choose the Lap Band as opposed to the gastric bypass, and those extra criteria are no longer required. Since this is a new development, your physician's office may not be aware of it. Good luck!

I have heard through the grapevine that in the next few weeks there may be a lawsuit filed against BC/BS of TX to challenge the legality of the 12 month supervised diet requirement. Perhaps they got wind of that and are becoming more lenient. Disclaimer: This is only hearsay on my part, and I am not alleging any wrongdoing by any party.

Medicaid eligibility is decided on a state by state basis. Call your state's Medicaid office and ask them if CPT code 43770 is covered. Good luck!

It appears Michigan Medicaid may cover the Lap Band. The CPT code for the Lap Band is 43770, and it appears to be covered. See the following link: http://www.michigan.gov/documents/MSA_05-70_143729_7.pdf Good luck!

See if your Lap Band surgeon has made arrangements for an evaluation by a nutritionist or dietician. As part of our program, all of our patients are evaluated by a registered dietitian. Call your surgeon's office, they should be able to help. Good luck!

Here's a picture of a tragic case of slippage. Not for the faint of heart.

Both my wife and I (both of us are surgeons) tell our Lap Band patients that we don't even care about their weight until the first adjustment. Most of our patients lose some weight because we ask them to be on a liquid diet post-operatively and then mushy food before transitioning back into a solid diet. But our belief is that we shouldn't expect weight loss until an adjustment or two is made, which won't be until more than a month after surgery. Regarding the brain transplant comment, I assume it was a joke and meant in jest. Besides, most insurance companies won't pre-authorize brain transplants without a 6 month history of medically guided attempts at gaining higher intelligence, and you must have documented a 5 year history of brain atrophy. A medical letter of necessity is also helpful, and of course you have to check to see if there is an outright exclusion on your policy.

Gastroparesis can also be seen in diabetics. Do you have diabetes?

Do you have a history of GERD (reflux)? If so, your doctor may want to get the Upper GI to evaluate if you have a large hiatal hernia that may change his/her approach to surgery.

There was an earlier thread that you might find helpful. http://www.lapbandtalk.com/showthread.php?t=12271 Good luck!

I have heard of an instance of it happening in the U.S. As to what the proper step would be, it depends on the specific situation I suppose. 1)For example, does the patient have a higher than average BMI making Lap Band placement more difficult. (Our average patient has a BMI of around 46, with the high 81.) 2) Does the patient have prior surgery with intra-abdominal adhesions, making surgery more difficult? 3) Does the patient have prior gastric surgery, such as a fundoplication, or gastric bypass, which might make the surgery more difficult.

That is possible, but very difficult to tell with static images. The upper GI is taken as a "movie" and the sequence would be helpful to see. 1) Supposing this is a misplaced band, WHICH IS ONLY A SUPPOSITION, I don't think it's a Mexico vs. US issue at all. 2) We currently perform upper GI swallows postoperatively before the patient goes home. However, we may change this practice. We have never had an instance where that upper GI test changed our management of the patient. Additionally, a few months ago a paper was published in the "Journal of the American College of Surgeons" from a group that performed over 1000 Lap Bands. They stopped doing upper GI swallows after their first 100 patients because the swallow didn't change any course of management. 3) Again, I don't think this is a Mexico vs. US, or Swedish vs. Inamed issue.

It's difficult to tell from your images what exactly is going on. Keep in mind that since many physicians in the US (including myself) have little or no experience with the Swedish Band that you had placed in Mexico. At first glance, looking at your pictures, I thought that the "Band" looked a bit off to the side, as if the stomach itself was not banded, but at the same time, it certainly does appear to show restriction to the barium flow. Do you have pictures from your endoscopy?

What I always found interesting with Aetna's requirement is that the FDA does NOT approve the Lap Band being put in patients with 1) Patients with cirrhosis or 2)Inflammatory bowel disease (see http://www.fda.gov/cdrh/pdf/P000008b.pdf); and surgeons may not choose to electively place the Lap Band in patients with conditions 3, 4 and 5. I will leave each to draw their own conclusions with regards to Aetna and their policy on Lap Bands

Medicare, while a federal program, is handled by different regional carriers throughout the country who can set their own rules. My understanding is that beginning this year, Medicare will cover bariatric surgery for patients under 65, but not for those over 65 years old.

With regards to Wadley vs. St Michael's, we have seen that insurance companies that cover St Michael's and not Wadley will provide out of network coverage for the Lap Band at Wadley. Dr. Keilin and I are on active staff at St Michael's as well as Wadley, but St Michael's does not offer the Lap Band. We have had a significant number of patients who have insurance that generally covers St Michaels only; they have the Lap Band covered at Wadley without any difficulties since the insurance company understands that the Lap Band is not an available procedure at St Michael's

Good luck! If they have any questions about the Band itself, point out to them that as of January 1, it has an official CPT code. (See the sticky thread http://www.lapbandtalk.com/showthread.php?t=11845 ) To be honest with you, I am surprised that people haven't jumped on the potential significance of the the CPT code come January 1. You see, until now, many insurance companies have said the Lap Band is investigational (even though I think about 200,000 have been placed worldwide) because a 'code' doesn't exist for it. Well, now it is official, and has a code that can be billed for it, just like gallbladder surgery, an office visit, immunizations shots, etc. I am hopeful that the new CPT code will cause many insurance companies to change their tune about the supposed 'investigational' nature of the Band.

I went to Tufts University School of Medicine in Boston, so I might be biased, but I would recommend you check out Dr. Scott Shikora, at http://www.obesityconsult.org/index.htm , who operates at the New England Medical Center. Dr. Shikora is a long time bariatric surgeon, and has peformed a large number number of bariatric operations. He started off many years ago performing gastric bypass, and also performs the Lap Band and offers that to his patients as well. I think there are potential benefits to being a patient in an established bariatric program. I remember when I was a medical student in Boston 10 years ago, hearing about Dr. Shikora and his bariatric program (at the time gastric bypass) and many of us thought to ourselves 'what is bariatric surgery?' He has been doing this for quite a long time compared with many other surgeons. Take a look at his website. Seems quite academic to me; links to nutritional websites, a list of their complication rate (how often do you see that?), info on medical weight loss. I'm impressed. Unfortunately as med student I never rotated on his service, so I have no first hand experience with him, but I did speak with him at the American Society of Bariatric Surgeons meeting a couple of years ago and he seemed like an extremely nice person. He is quite popular on the academic lecture circuit for bariatric surgery, and seems to be a genuine advocate for patients trying to overcome the disease of morbid obesity.

From Aetna's clinical policy bulletin ( http://www.aetna.com/cpb/data/CPBA0157.html ) I have cut and pasted just one small section here from the entire bulletin. ---------------------------------------------------------------- Vertical Banded Gastroplasty (VBG) and Laparoscopic Adjustable Silicone Gastric Banding (LASGB or Lap-Band): Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) or laparoscopic adjustable silicone gastric banding (LASGB, Lap-Band) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following comorbid medical conditions: Hepatic cirrhosis with elevated liver function tests; or Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or Radiation enteritis; or Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV) (see Appendix). --------------------------------------------------------- Basically it appears that they would prefer you to get a gastric bypass because it appears to indicate that a Lap Band would be approved only if you are a poor candidate for a gastric bypass.

We would never deny chemotherapy from someone with metastatic cancer which might have a 6 month likelihood of survival. It is all a matter of public perception as to what we 'expect' from our healthcare system. I personally think there are much more frivilous uses of healthcare dollars than bariatric surgery. 1) Approximately 127 million adults in the U.S. are overweight, 60 million obese. Does anyone really think this is simply a disease of laziness? If so, are 127 million Americans lazy? That is rather disparaging to suggest that. Also, the IRS accepted obesity to be a "medical disease in its own right" in 2002. 2) See above But I suppose I'm preaching to the choir here. It's other people that need to be made aware.

See the 'sticky' thread above regarding the CPT code. This provides a standardized approach to gastric band surgery charging and reimbursement.

There is no 'permanent/official' CPT code for adjustments as of yet.

We've had at least one if not more patients have this timing occur to them. We would suggest wearing a pad. It's no big deal. Good luck tomorrow!

In the USA only one type of Band is FDA (food and Drug Administration)approved; that is the Lap Band from Inamed.

See other threads for discussions on Walter Lindstrom at www.obesitylaw.com He is a lawyer who had the GB, then a Lap Band, and is an advocate for obesity discrimination and getting insurance companies to pay for obesity surgery.