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I had a friend that went to Dr Joya for her lapband and then again her her revision to RNY. She can't say enough good things about him, his staff and the facility.

Stomaphyx is Bariatric revision for Gastric Bypass patients who are regaining weight. Not something that would be performed on a Gastric Sleeve Patient. People typically get this when they have stretched their pouch. Sleevers have less likelihood of doing so.

I found experimentation to be the best thing. An egg mixes well with tuna and makes a nice patty with a little olive oil. Sprinkle some salt on it and u have a crispy tuna patty - tons of protein too. Maybe some crab meat? Shrimp sautéed in a little butter and seasoned well? Salmon patties? Chicken salad? It's not the meat that won't sit well, it's the DRY meat. Add some moisture with butter, gravy, etc. make it more medium than well done. The point behind no corn or enriched flower the first couple months in the more successful programs is because our bodies NEED protein and theirs ZERO need for enriched flour and corn. Some of these programs around are nothing more than herding fat people thru a turnstile and knowing they will be back for revisions. Do some research. Don't eat enriched flour or corn. Don't drink alcohol, etc etc. Make smart decisions.

I had revision from lapband to ds on June 7... 2 nights in the hospital and I’m home and I’ve even worked from home nearly all day today. This is way harder than lapband or csection ( I had 2 of those ) I had 2 week pre op diet, week 1 was 2 shakes 2 snacks and a lean green dinner week 2 was all shakes and I was down 13lb when I went in for surgery. I’m so puffed up now from IV fluids the scale showed back up 10lb so I’m staying away from that thing a few days.

What kind of BCBS coverage do you have? When I had my initial sleeve surgery (and my revision an year later to bypass due to complications) I had BCBS (the highest Diamond plan) and they approved my initial surgery in 48 hours once it was submitted and 72 hours for my revision once it was submitted. I know some plans don't offer a lot of coverage, or require a thousand hoops to get an approval.

That's not really correct, you *can* get your Lap Band done through Australia's public system if you're willing to wait long enough and if you have a doctor that operates in the public system. Not many doctors do. To do so, you'd have to contact the hospital and see who they recommend, but just as a guide, the waiting list at The Alfred in Melbourne has been up to 7 years long at times. But cosmetic surgery is an entirely different matter, you'd have to convince a surgeon to give you an item number for the surgery and they're unlikely to because the need for a tummy tuck is not considered to be related to your health the way a Lap Band is. Its cosmetic, and you might get a portion covered (like about $100) but not much more. There's item numbers for things like breast reductions, but then you have to weigh up that the surgeon's taht do them are mostly private and will charge well and above the scheduled fee by thousands of dollars. To find someone to do it in the public system, you're going to again face a long waiting list. And even then, its not completely free, you get 85% of the scheduled fee back, so if your surgeon charges more, you're out of pocket. I would think that you'd almost always have to find a cosmetic surgeon in the private sector becuase of the nature of cosmetic surgery which means it will be done in a private hospital so if you have no private health insurance, you're up for well over $1000 a night for the bed as well. You just really cannot get cosmetic surgery done without private health insurance unless its some sort of urgent disfigurement or similar. When you weigh it up, waiting several years on a waiting list for your band and for any cosmetic surgery, having to pay for aftercare, etc why would you not just take out private health insurance, wait a year to qualify, have the surgery etc? It will cost you little more in the long run and you're not in strife if you need any revision surgery etc. And waiting the year, you'll probably get done a whole lot sooner.

Sorry to hear of your difficulties, but best wishes to you. Are you planning on having a revision in the future?

Ok hi ladies. I was banded in March of 2005. The good news is that I had, at one time, lost from 285lbs down to 150lbs. However, I got to that 150lbs because I was starving. In early 2006 after I got be around 170lbs, my band slipped and I could not eat for two weeks. I could'nt even keep water down so I had revision surgery and they fixed the slip. Since then I was so scared to get a fill so I went without one for almost a year. By this time I had gained back up to 180lbs. Gradually I started getting fills until I now, and I have 3.1 in a 4cc band. I have not had any restriction whatsoever since my last surgery. Each fill feals the same. My doctor seems to think that I am just not following the band rules and by the way I feel like a failure because I am now up to 225lbs! Omg back over 200lbs! I know this isnt as high as before and I know I can lose it but I just need my band to help me out. I know I have to work hard and I am ready to do that. I admit I have made many mistakes but I do need that little bit of help from the band to let me know I am full. My doctor won't put anymore in my band until I take a nutrition class and have an upper GI to see if it slipped again due to my history. It doesnt feel like a slip because the first time It slipped I couldnt even eat and now I can eat anything I want....I mean ANYTHING! I know just because I can, doesnt mean I should but why the hell did I get this band if it isn't going to give me some help? Ya know? Anyway, I lost 135lbs once before so I know I can lose 60lbs, I just hope it hasn't slipped again. Could it be that my pouch has stretched over time and I just need to shrink it? I was thinking maybe if I went on a liquid diet for a week or so that it might help shrink it if indeed that is the case. Anyone have any suggestions? My upper GI should be scheduled soon and I am just waiting on the DR to call me. I am on my second day of liquids and I just figured that at least this might jumpstart my weightloss....if anything.

I really don't remember how long it was before the day I think the port actually came up, but it was like close to a month, I think. Unfortunately, it was not for a few months after that when my doctor FINALLY confirmed this. I had revision surgery in August. In considering this surgery I asked about the low profile port also, but my doctor convinced me against it. I don't remember why, but whatever it was it must have sounded rational. I knew shortly after the revision surgery that the sutures didn't take AGAIN, but my doctor was convinced they had and that all was fine. (He is great at appeasing me). So now, I see him yesterday to discuss my symptoms and thoughts about my band having slipped. He sent me for a CT scan. I had the test, and the doctor on staff read the results and reported to my doctor. My doctor "promised" me that my band is fine...but I "have a pnuemonia" in my left lung. I have no idea wtf that means, but apparently I'm pretty sick lol. Needless to say I am asymptomatic, and have decided to go for a second opinion on Monday. Oh, but in all this my doctor said I was right and that my port did in fact come up again. Apparently, I have very resistant stomach muscles. I'll keep you posted. I have a question though. Has anyone felt that they have been getting sicker easier since the rapid weight loss? Like maybe more susceptible to things, maybe from compromised immune systems or something? I've been sicker this year than I can remember previous years.

Hi Everyone- just wanted to post a quick update- I'm trying hard to stay on plan and at around 1000 calories a day. Its hard- especially with zero restriction. I'm also moving my big rear and walking a mile every day! I will be glad to get a fill on Friday and back to being able to eat only small amounts. It's comical (almost) that just a few weeks ago I was whining about not being able to eat 'normal' foods and wishing for the days when I'd be able to eat them. Now I'm wishing I could go back to the restricted feeling. LOL. I swear I am a gas factory. LOTS of foods and even exercise I find, gives me gas- or lets me expel the gas- LOL. I'm feeling much better about having my port revision and am slowly but surely coming out of that depressed mood that I had gotten into. I appreciate everyone who msg'd me and checked on me. I will update on Friday as soon as I'm home from the procedure. Thank the lucky lord Dr. B says I don't have to have the zappy wrist thing again- Its crazy, but the only thing I really am dreading is the darn IV- which should tell any newbie that the actual procedure is not that bad at all!! Everyone's progress looks great! Hopefully soon I'll be back to seeing the numbers go DOWN!!

I don't have my surgery date set yet, but come cash or high water, I'm doing it. I'm revising from the band. I have to have an EGD on 1/4/13 to see what kind of damage if any my band has done. Hoping the insurance will pay for the revision since they payed for the band, but not holding my breath. I'm so ready to do this!! So miserable and unhappy wih my weight. Good luck to all of you with early January dates!! Congrats!

The port issue is the problem I had. My port ripped up from the muscle. The pain was slight over time, and then became excruciating, which ended me up in the ER. That was the day the stitches must have actually come up. The initial pain was just leading up to the inevitable, I suppose. I had the revision surgery in August, but um, I don't think the stitches held that time either...shocking lol. I have little dumb problems ALL THE TIME. I figure I don't want to mess with the port much because it is somewhat of an advantage, in the event I want to have the band removed in time, I have an argument for insurance to cover the procedure. The pain is mild and irritating, but nothing debilitating. Next problem...why do I think my bad slipped? I hope I am being a hypochondriac (I am sure I didn't spell that right, but too lazy to spell check). Anyhow, the last few weeks I have difficulty getting even liquids down. Lately, with solid food, some time after I eat it, if I am sitting down it seems that the food has been broken down into a more liquid form and I begin to regurgitate and choke. And I suffer a lot of heartburn. I googled all these symptoms...and I find band slippage. GREAT!!! I see my not-so-helpful doctor on Friday. Um thank God it isn't an emergency! I'll keep you guys posted. 7....more....lbs. That's it lol

Neal, sorry you need a revision so soon, did doc mention recovery time? Karey, i'll see if DH can take some illustration pics to help describe what im talking about. it gets better... really :eek: Marypetunia, yay .. i'll be thinking of you tomorrow. youre the last of the bunch! what time are you going in? i way overdid it today. very sore, extremely swollen, so much that the jeans that fit this morning with a little room in the waist were TIGHT when i got home.. and they are stretchy.

Sorry I don't check in as often lately. Good to see everyone is doing well. I am doing pretty good. I am like you though, all I have done is eat since PS. My Dr said not to diet while I heal. Well, I certainly can not be accused of dieting. I started back to day being good. I wasn't unfilled prior to PS, but have never been really tight anyways. I called and cheduled a fill for April 4th. I really need it. I am having revision done on May 21st and I want maximum results, so I am really buckling down, even before my fill. Swelling is getting better. I am now wearing my pre-op pants finally, though are still a little snug. The great thing is that when I wear someting tight now, nothing hangs over my belt and no once can tell they are snug.

I went to see my doctor today. He put me under the fluro to check my band. The placememt is fine, no slippage. He did the barium swallow test and saw that it is taking me longer than normal to pass the liquid. He tried to do the unfill and couldn't get to my port because, not only has it moved to what seems to be a land far far away, it is also upside down. He is going to do the revision and cut the cathedar. Apparently since I have lost so much weight it is all curled around. It is outpatient, and I am going to sit patiently until he can squeeze me in. I'll keep you all updated!

Congrats on your surgery date. My revision is on Friday so maybe we'll run into each other. I can't wait! I'm a little nervous, any surgery makes me nervous, but am so ready to get a fill and get on with this.

4 days post surgery and I do feel better today. I actually slept about 6 hours straight! Ingesting 64-ounces of fluids is quite difficult for me. I managed 42 ounces yesterday and this was tough. Focused on getting proteins and vitamins first then other fluids. More pain than I had anticipated, but I was comparing it to my lap band surgery 5 years ago. As for not having my Lap-Band - it is odd not feeling the port and always feeling the actual Lap-Band tight on my stomach. Anybody else have a Lap-Band / Sleeve revision? I am actually contemplating going back to work tomorrow - probably not a good idea.

Hello, everyone! I have posted previously in this thread about my horrible reflux since my sleeve surgery July 2012. I finally had the barium X-ray last week & am now sitting here with a Bravo monitor that was placed yesterday. I kept putting these tests off because they are so awful to do & I wasn't sure I wanted to go thru bypass surgey. Well, the Prilosec & Zantac that I have been taking daily for almost 2 years seems to not be working. I see the surgeon 5/15, so will know then if I can get a revision to bypass.. I NEVER had reflux when I was overweight & I would eat lots of junk!! Im also lactose intolerant now so it is difficult for me to eat. The good thing is I now weigh 122 lbs!! However, I would give anything to be able to eat fruit, veggies, salad once in awhile ! Maybe even enjoy an ice cream cone! Take care!!

MGB is short for Mini-Gastric Bypass. Revision weight loss surgery is a surgical procedure that is performed on patients who have already undergone a form of bariatric surgery, and have either had complications from such surgery or have not successfully achieved significant weight loss results from the initial surgery.

I just got out of the ER...no slippage or erosion.Will I still get a revision by NJ Horizon Health

I am post op from revision and can’t tolerate the shakes either. I am using bone broth, unjury chicken broth and fat free fairlife milk instead. I also drink the clear protein 2o drinks.

I had my first fill on 10-10. It was awesome and instantaneous. Just right and worked quite well. At my 6 month check-up we discussed another fill because I did feel I was starting to 'empty out' more rapidly and occasionally experiencing hunger between dinner and bedtime. Unfortunately, my port had flipped so I didn't get that second fill until I had my port revision last Thursday. Again, it seemed everything was fine, I was on liquids a day or two and then seemed to eat 'normally', but on the 4th and 5th days -- I'm barely able to get 1/4 of my usual Instant Breakfast shake down. Literally one or two bites at a meal and I am full for several hours. My Fluid intake is WAY, WAY down, too! I remember hearing a long time ago that sometimes it takes a day or two to know how the fill "took". Any ideas on what this is? Did this fill just take a few days to "take"? I don't think my port being moved would cause swelling near the band to make restriction more severe....but what do I know!! I'm happy with the weight loss, but dubious how long I can subsist on what I'm able to get past the band right now. Ah, banding -- it's a journey, not a destination, eh?

Dr Kurian was my surgeon, I had my lap band revised to gastric bypass.. I love her to bits. Just saw her yesterday for my six week post op appointment. I highly reccomend her!!

Originally Posted by Lap_dancer From BCBS Association (corporate) . 5. The improvement must be attainable outside the investigational settings. The improvement in health outcomes for laparoscopic gastric bypass can be attained outside the investigational setting, if the training of surgeons and the programmatic elements are similar to programs in the published literature, and if performed at a hospital with sufficient surgical volume. However, there may be considerable variation in capabilities and resources among different bariatric surgery programs. To address this concern, Blue Cross and Blue Shield Association and the American College of Surgeons have developed criteria for credentialing and tracking outcomes from bariatric surgery programs. Based on the above, laparoscopic gastric bypass meets the TEC criteria, when performed in appropriately selected patients, by surgeons who are adequately trained and experienced in the specific techniques used, and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery. http://www.bcbs.com/betterknowledge/.../20/20_15.html Source found at above website. Yeah, but isn't this just for gastric bypass? I couldn't find anything about gastric banding in this document. JB .................................................................................................. Airman, think of doing searches on this subject like a crossword puzzle. Just because you have a th_ _ K doesn't mean the word is think. You won't find some of the information easily. You should keep track of your searches via your search engine history. Book mark things, reduce the screen and open up another window to continue a new search. Open WORD and copy and paste links and language from documents. ( I do this all the time when I am researching). I'm not an insurance agent but here is what I have learned about Blue Cross and Blue Shield. Blue Cross and Blue Shield (BCBS) is like a mall. Inside the mall you have different stores that you can shop from. So you get Blue Cross, Blue Shield, Blue, Blue Options, ... Google is a good friend. Please utilize this in your efforts to gain information available to you. Google entry from me was: BCBS South Carolina weight loss surgery HITS: Suburban Surgical Care Specialists, S.C. - Bariatric Surgery Vanderbilt Center for Surgical Weight Loss, Exclusion List The Next Step for Weight-Loss Surgery Blue Distinction Centers for Bariatric Surgery That one sounds good, I think I'll try it......... (thinking, if BCBS doesn't cover it and thinks Lap Band is experimental, I won't find a hit on my search ) Inside this HIT I see it is the BCBS site, I'l go to SEARCH and type in GASTRIC HIT: Displaying results 1 - 5 of 5 items found. 1. TEC in Press - Laparoscopic Adjustable Gastric Banding for Morbid Obesity (Web Page; Thu Jan 25 15:43:00 EST 2007) EXECUTIVE SUMMARY Background: Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and this weight loss leads to net improvements in health outcomes. Among different surgical procedures,... Description: Laparoscopic Adjustable Gastric Banding for Morbid Obesity 2. Laparoscopic Gastric Bypass Surgery for Morbid Obesity (Web Page; Mon Oct 30 15:26:00 EST 2006) Assessment ProgramVolume 20, No. 15 February 2006Executive Summary Background Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and evidence exists that this weight loss leads to net... Description: Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and evidence exists that this weight loss leads to net improvements in health outcomes. 3. Newer Techniques in Bariatric Surgery for Morbid Obesity: Laparoscopic Adjustable Gastric Banding, Biliopancreatic Diversion, and Long-Limb Gastric Bypass (Web Page; Mon Oct 30 15:27:00 EST 2006) Assessment ProgramVolume 20, No. 5 August 2005Executive Summary Morbid obesity, generally defined as a body-mass index (BMI) of 40 kg/m2 or greater, is associated with excess mortality and a high burden of obesity-related morbidities.... Description: Morbid obesity, generally defined as a body-mass index (BMI) of 40 kg/m2 or greater, is associated with excess mortality and a high burden of obesity-related morbidities. HIT: TEC in Press - Laparoscopic Adjustable Gastric Banding for Morbid Obesity EXECUTIVE SUMMARY Background: Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and this weight loss leads to net improvements in health outcomes. Among different surgical procedures, gastric bypass is the most common procedure performed in the U.S., and offers the most favorable benefit/risk ratio among established procedures. Laparoscopic adjustable gastric banding (LAGB) is an alternative technique that has the potential advantages of being less invasive and reversible. Prior TEC Assessments have concluded that LAGB does not meet the TEC criteria. Objective: To review the available evidence on whether LAGB results in similar improvements in health outcomes as does open or laparoscopic gastric bypass (GBY). Search strategy: MEDLINE search for the period of 1980 through September 2006, supplemented by hand search of bibliographies and search of Cochrane database. This goes on but it tells me that they are NOT calling it "investigational." PRINT AND SAVE 1. The technology must have final approval from the appropriate governmental regulatory bodies. Bariatric surgery itself is a procedure and is not subject to U.S. food and Drug Administration (FDA) regulations. However, certain devices that may be used as part of the procedure may be subject to FDA approval. The Lap-Band® system received premarket application (PMA) approval by the FDA in June 2001 for use in morbidly obese patients. 2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes. The evidence is sufficient to permit conclusions concerning the short-term safety and efficacy of LAGB in comparison with GBY. Weight loss at 1 year following LAGB is substantial, in the range of 40% EWL, although less than that seen following GBY. The short-term complications of LAGB are very low, with serious short-term complications being uncommon, and mortality exceedingly rare. Rates of short-term adverse events, including serious procedural complications and mortality, are lower for LAGB compared with GBY. Same page, further on down the page. Airwayman, I could truthfully sit here for the next span of time and do this research for you but in the end, it teaches you nothing on perserverance. I am a teacher. I teach my students that perserverance pays off. In the frustration of learning, there is victory in the end. *I began my own Quest knowing NOTHING about the surgery, my own insurance plan nor how the process works. After six months, I can answer pretty much any question thrown my way. Tomorrow I will get my chance to educate the insurance committee at work. They were told "gastric surgery is not covered by Blue Cross", I beg to differ. http://mcgs.bcbsfl.com/ Search: Medical Coverage Guidelines BCBS HIT: 1.(61.06% Relevant)Gastric Electrical Stimulation... peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver 0155T Laparoscopy, surgical, implantation or replacement of gastric stimulation electrodes, lesser curvature ...2.(59.05% Relevant)Gastric Bypass Revision... gastrectomy or intestine resection; with vagotomy 43886 Gastric restrictive procedure, open; revision of subcutaneous port component only 43887 Gastric restrictive procedure, open; removal of subcutaneous port component only 43888 Gastric restrictive procedure, open; removal and replacement of ...>>3.(58.83% Relevant)Surgery for Clinically Severe Obesity... or stapling along the horizontal or vertical axis). Unlike the traditional gastric bypass, which is essentially a gastric restrictive procedure, these very long limb Roux-en-Y gastric bypasses combine gastric restriction with some element of malabsorptive procedure, depending on the location of the ... 02-40000-10 Original Effective Date: 10/15/99 Reviewed: 04/27/06 Revised: 05/15/06 Next Review: 04/26/07 Subject: Surgery for Clinically Severe Obesity (Bariatric Surgery; Gastric Bypass Surgery) THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION. Non-Covered Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines Other References Updates DESCRIPTION: Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. For purposes of this medical coverage guideline, clinically severe obesity is defined as a body mass index (BMI) of 35 kg/m2 or greater. See the height and weight tables for Men and Woman, BMI tables (100-195, 200-295, 300-400, and formula for calculating a BMI. Several surgical (bariatric) procedures are used for the treatment of clinically severe obesity. These procedures can be categorized as follows:

http://mcgs.bcbsfl.com/ Note the timeline on this: 02-40000-10 Original Effective Date: 10/15/99 Reviewed: 04/27/06 Revised: 05/15/06 Next Review: 04/26/07 Subject: Surgery for Clinically Severe Obesity (Bariatric Surgery; Gastric Bypass Surgery) DESCRIPTION: Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. For purposes of this medical coverage guideline, clinically severe obesity is defined as a body mass index (BMI) of 35 kg/m2 or greater. See the height and weight tables for Men and Woman, BMI tables (100-195, 200-295, 300-400, and formula for calculating a BMI. Several surgical (bariatric) procedures are used for the treatment of clinically severe obesity. These procedures can be categorized as follows: <LI class=bulletedList-1>Malabsorptive procedures - alteration of the intestinal absorption limiting nutrients available to the body OR Gastric restrictive procedures - reduction in the capacity of the stomach thereby limiting the amount of food ingested. Gastric surgical procedures for the treatment of clinically severe obesity include: <LI class=bulletedList-1>gastric bypass where approximately 90% of the stomach is bypassed and reattached to the proximal jejunum OR gastric stapling, vertically banded gastric partition, or vertically banded gastroplasty where a proximal pouch of 30-60 ml and a one centimeter outlet are created by a row of vertical staples and a horizontally placed reinforcing band. WHEN SERVICES ARE COVERED: Effective January 1 2005, weight loss surgery is not covered for most contracts. Please refer to the individual member’s contract benefit language. NOTE: The primary care physician must provide a letter with facts supporting medical necessity, for review by the Medical Director. Certain surgical procedures performed for the treatment of clinically severe obesity may be considered medically necessary when ALL of the following conditions are met: The member: <LI class=bulletedList-1>meets the above definition of clinically severe obesity, <LI class=bulletedList-1>has been severely obese for at least five (5) years, <LI class=bulletedList-1>has attempted a physician supervised (by the primary care physician) non-surgical management weight loss program (e.g., diet, exercise, drugs) for six (6) consecutive months <LI class=bulletedList-1>has received psychological or psychiatric evaluation with counseling as needed, prior to surgical intervention; does not have a medically treatable cause for the obesity, (e.g., thyroid or other endocrine disorder). The following procedures may be considered medically necessary when the above criteria has been met: Vertical-Banded Gastroplasty (CPT code 43842) Vertical-banded gastroplasty was formerly one of the most common gastric restrictive procedures performed in this country but has more recently declined in popularity. In this procedure, the stomach is segmented along its vertical axis. To create a durable reinforced and rate-limiting stoma at the distal end of the pouch, a plug of stomach is removed, and a propylene collar is placed through this hole and then stapled to itself. Because the normal flow of food is preserved, metabolic complications are uncommon. Complications include esophageal reflux, dilation, or obstruction of the stoma, with the latter 2 requiring reoperation. Dilation of the stoma is a common reason for weight regain. Vertical-banded gastroplasty may be performed using an open or laparoscopic approach. Roux-en-Y Gastric Bypass (CPT code 43644, 43846) Gastric bypass may be performed with either an open or laparoscopic technique. The original gastric bypass surgeries were based on the observation that post-gastrectomy patients tended to lose weight. The current procedure involves a horizontal or vertical partition of the stomach in association with a Roux-en-Y procedure (i.e., a gastrojejunal anastomosis). Thus, the flow of food bypasses the duodenum and proximal small bowel. The procedure may also be associated with an unpleasant “dumping syndrome,” in which a large osmotic load delivered directly to the jejunum from the stomach produces abdominal pain OR vomiting. The dumping syndrome may further reduce intake, particularly in “sweets eaters”. Operative complications include leakage and marginal ulceration at the anastomotic site. Because the normal flow of food is disrupted, there are more metabolic complications compared to other gastric restrictive procedures. These complications may include iron deficiency anemia, vitamin B-12 deficiency, and hypocalcemia, all of which can be corrected by oral supplementation. Another concern is the ability to evaluate the “blind” bypassed portion of the stomach. Long Limb Gastric Bypass (i.e., more than 100 cm) (CPT code 43847) Recently, variations of gastric bypass procedures have been described, consisting primarily of long limb Roux-en-Y procedures, which vary in the length of the alimentary and common limbs. For example, the stomach may be divided with a long segment of the jejunum (instead of ileum) anastomosed to the proximal gastric stump, creating the alimentary limb. The remaining pancreaticobiliary limb, consisting of stomach remnant, duodenum, and length of proximal jejunum is then anastomosed to the ileum, creating a common limb of variable length in which the ingested food mixes with the pancreaticobiliary juices. While the long alimentary limb permits absorption of most nutrients, the short common limb primarily limits absorption of fats. The stomach may be bypassed in a variety of ways (i.e., either by resection or stapling along the horizontal or vertical axis). Unlike the traditional gastric bypass, which is essentially a gastric restrictive procedure, these very long limb Roux-en-Y gastric bypasses combine gastric restriction with some element of malabsorptive procedure, depending on the location of the anastomoses. NOTE: Coverage of long limb Roux-en-Y procedures is limited to 150 cm. Adjustable gastric banding (i.e., Lap-Band Adjustable Gastric Banding System) (CPT code 43770, 43771, 43772, 43773, 43774) Adjustable gastric banding involves placing a gastric band around the exterior of the stomach. The band is attached to a reservoir that is implanted subcutaneously in the rectus sheath. Injecting the reservoir with saline will alter the diameter of the gastric band; therefore, the rate- limiting stoma in the stomach can be progressively narrowed to induce greater weight loss, or expanded if complications develop. Because the stomach is not entered, the surgery and any revisions, if necessary, are relatively simple. Complications include slippage of the external band or band erosion through the gastric wall. Adjustable gastric banding has been widely used in Europe. Currently, the U.S. Food and Drug Administration (FDA) has approved one such device for marketing in the United States, Lap-Band (BioEnterics, Carpentiera, CA). The labeled indications for this device are as follows: "The Lap-Band system is indicated for use in weight reduction for severely obese patients with a body mass index (BMI) of at least 40 or a BMI of at least 35 with one or more severe comorbid conditions, or those who are 100 lbs or more over their estimated ideal weight according to the 1983 Metropolitan Life Insurance Tables (use the midpoint for medium frame). It is indicated for use only in severely obese adult patients who have failed more conservative weight-reduction alternatives, such as supervised diet, exercise and behavior modification programs. Patients who elect to have this surgery must make the commitment to accept significant changes in their eating habits for the rest of their lives." Biliopancreatic Bypass with Duodenal Switch (43845) The duodenal switch procedure is essentially a variant of the biliopancreatic bypass. However, instead of performing a distal gastrectomy, a “sleeve” gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum, similar to the above procedure, to create the alimentary limb. Preservation of the pyloric sphincter is designed to be more physiologic. The sleeve gastrectomy decreases the volume of the stomach and also decreases the parietal cell mass, with the intent of decreasing the incidence of ulcers at the duodenoileal anastomosis. However, the basic principle of the procedure is similar to that of the biliopancreatic bypass (i.e., producing selective malabsorption by limiting the food digestion and absorption to a short common ileal segment). WHEN SERVICES ARE NOT COVERED: Surgery for clinically severe obesity is not covered when these services are excluded from the member’s contract benefits. Studies are needed to determine the long-term health outcomes of the following procedures, therefore the procedures listed below are considered investigational when performed for the treatment of clinically severe obesity: Biliopancreatic Bypass Procedure (i.e., the Scopinaro procedure) (CPT code 43847) Biliopancreatic bypass (BPB) procedure, developed and used extensively in Italy, was designed to address some of the drawbacks of the original intestinal bypass procedures that have been abandoned due to unacceptable metabolic complications. Many of the complications were thought to be related to bacterial overgrowth and toxin production in the blind, bypassed segment. In contrast, BPB consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure. This procedure consists of the following components: <LI class=bulletedList-1>A distal gastrectomy functions to induce a temporary early satiety OR the dumping syndrome in the early postoperative period, both of which limit food intake <LI class=bulletedList-1>A 200-cm long “alimentary tract” consists of 200 cm of ileum connecting the stomach to a common distal segment <LI class=bulletedList-1>A 300- to 400-cm “biliary tract,” which connects the duodenum, jejunum, and remaining ileum to the common distal segment <LI class=bulletedList-1>A 50- to 100-cm “common tract,” where food from the alimentary tract mixes with biliopancreatic juices from the biliary tract. Food digestion and absorption, particularly of fats and starches, are therefore limited to this small segment of bowel (i.e., creating a selective malabsorption). The length of the common segment will influence the degree of malabsorption Because of the high incidence of cholelithiasis associated with the procedure, patients typically undergo an associated cholecystectomy. Many potential metabolic complications are related to biliopancreatic bypass, including most prominently iron deficiency anemia, protein malnutrition, hypocalcemia, and bone demineralization. Protein malnutrition may require treatment with total parenteral nutrition (TPN). In addition, there have been several case reports of liver failure resulting in death or liver transplant. Mini-Gastric Bypass (no specific CPT code) Recently, a variant of the gastric bypass, called the “mini-gastric bypass” has been popularized. Using a laparoscopic approach, the stomach is segmented, similar to a traditional gastric bypass, but instead of creating a Roux-en-Y anastomosis, the jejunum is anastomosed directly to the stomach, similar to a Billroth II procedure. This unique aspect of this procedure is not based on its laparoscopic approach, but rather the type of anastomosis used. NOTE: CPT code 43846 does not accurately describe the mini-gastric bypass, since this CPT code explicitly describes a Roux-en-Y gastroenterostomy, which is not used in the mini-gastric bypass. The following procedures reported as gastric bypass or gastroplasty are also considered investigational due to the lack of clinical studies to support effects on health outcomes: <LI class=bulletedList-1>jejunoileal bypass <LI class=bulletedList-1>gastric wrapping Garren-Edwards gastric bubble. BILLING/CODING INFORMATION: CPT Coding: 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (Roux limb 150 cm or less) 43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption (investigational) 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components) 43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric band component only 43772 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component only 43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component only 43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band and subcutaneous port components 43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty 43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty (investigational) 43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy (may be done laparoscopically) 43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption (may be done laparoscopically) There is no specific CPT or HCPCS code to report mini gastric bypass. A laparoscopic approach is used with the mini-gastric bypass. The stomach is segmented similar to a traditional gastric bypass; the jejunum is anastomosed directly to the stomach, similar to a Billroth II procedure. The mini gastric bypass is not based on its laparoscopic approach, but rather the type of anastomosis used. HCPCS Coding S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline ICD-9 Diagnoses Codes That Support Medical Necessity: 278.01 Morbid obesity REIMBURSEMENT INFORMATION: Bariatric surgical procedures are limited to individuals 18 years and older and are reimbursed based on the procedure performed and not the surgical technique used (e.g., microsurgical, laser, laparoscopic). PROGRAM EXCEPTIONS: Federal Employee Program (FEP): Follow FEP guidelines. State Account Organization (SAO): Follow SAO guidelines. DEFINITIONS: Biliopancreatic bypass: gastric restriction rerouting bile and pancreatic juice to the distal ileum. Garren-Edwards gastric bubble: a free-floating intragastric device made of elastomeric plastic is placed in the stomach via a gastroscope, used for reducing stomach capacity. Gastric wrapping: the stomach is folded over on itself and a full stomach wrap, i.e. polypropylene mesh, is applied to limit gastric volume. Gastric banding: a synthetic band rather than staples is used to divide the stomach into a small upper pouch and a lower portion). Gastric bubble: see definition of Garren-Edwards gastric bubble. Jejunoileal bypass: shunts food from the jejunum into the ileum, bypassing the small intestine. Morbid obesity: defined as a body mass index (BMI) of 40 kg/m2 or greater. Satiety: the quality or state of being fed or gratified to or beyond capacity. RELATED GUIDELINES: Gastric Bypass Revision, 02-40000-11 OTHER: Other index terms for gastric surgery: Adjustable gastric banding Bariatric surgery Gastric bypass surgery Lap-Band System Mini gastric bypass Billroth II Long limb gastric bypass Roux-en-Y Scopinaro Vertical banding REFERENCES: <LI value=1>All-plan survey (Blue Cross Blue Shield plans) <LI value=2>American Academy of Medicine CPT Coding (current edition) <LI value=3>Blue Cross Blue Shield Association TEC Evaluation (12/88), 2003 <LI value=4>Blue Cross Blue Shield Association TEC Special Report: The relationship between weight loss and changes in morbidity following bariatric surgery for morbid obesity. BCBSA TEC Assessment Program, 2003; 18:1-25 <LI value=5>Blue Cross Blue Shield Association-Surgery for Morbid Obesity (7.01.47), 12/14/05 <LI value=6>DeMaria, E J, Sugerman, H J, Meador, J G, et al. High Failure Rate After Laparoscopic Adjustable Silicone Gastric Banding for Treatment of Morbid Obesity. Annals of Surgery 2001:233:809-818 <LI value=7>First Coast Service Options (FCSO) Medical Policy - surgical Management of Morbid Obesity, LCD #L14600 (01/01/06) <LI value=8>Guidance for Treatment of Adult Obesity, American Obesity Assoc., 1998 <LI value=9>Hayes Medical Technology Directory - Laproscopic Bariatric Surgery - us.lapa0008.2005 (11/03; Update report 12/05) <LI value=10>Hayes Medical Technology Directory - Obesity Management, Surgical Approaches OBES0802.03 (10/99; updated 07/27/02; updated 04/04/03) <LI value=11>InterQual Care Planning Criteria: General Surgery; Weight Loss Surgery GS-23 (2003) <LI value=12>National Institutes of Health Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity Statement (March 25-27, 1991) <LI value=13>Rutledge MD, Robert. “The Mini-Gastric Bypass: Experience with the First 1,274 Cases”; Obesity Surgery 2001; 11:276-280 <LI value=14>St. Anthony’s ICD-9-CM code book (current edition) U.S. Food and Administration (FDA) Talk Paper, FDA Approves Implanted Stomach Band To Treat Severe Obesity, T01-26, 06/05/01 COMMITTEE APPROVAL: This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/27/06. GUIDELINE UPDATE INFORMATION: 10/15/99 Medical Coverage Guideline developed. 09/15/01 Various revisions. 01/01/02 Coding changes. 10/15/02 Annual review. Added Roux-enY anastomosis or vertical-banded as covered services. Added biliopancreatic bypass with duodenal switch and very long limb gastric bypass procedure (e.g., greater than 100 cm) as non-covered services. 05/15/03 Revised to clarify coding of the various procedures; criteria revised and is consistent with Inter-Qual criteria. 09/15/03 Coverage criteria for psychological testing/counseling revised. 10/15/03 Reversed investigational status for CPT code 43847 and provided coverage criteria for long-limb Roux-en-Y procedures up to 150 cm. 01/01/04 Annual HCPCS coding update. 04/01/04 2nd Quarter HCPCS coding update; added S2082 and S2083. 07/15/04 Scheduled review; no changes. 01/01/05 HCPCS coding update. Added 43644, 43645, 43845, S2082, and S2083. Revised descriptor for 43846, and deleted S2085. 05/15/05 Unscheduled review of the non-covered statement for laparoscopic adjustable gastric banding (Lap-Band); coverage statement unchanged. 01/01/06 Annual HCPCS coding update (added 43770-43774; deleted S2082). 04/15/06 Scheduled review; removed investigational statement for laparoscopic adjustable gastric banding and biliopancreatic diversion with duodenal switch; updated coding, index terms, and references. 05/15/06 Scheduled review; removed investigational statement for laparoscopic adjustable gastric banding and biliopancreatic diversion with duodenal switch; updated coding, index terms, and references; added age limitation of 18 years and older. Private Property of Blue Cross and Blue Shield of Florida. This medical coverage guideline is Copyright 2006, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.