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I'm also having a very hard time with the protien shakes. They want me to get 5 ensures down! Yea right! So I switched to unjury powder and fairlife milk. Much thinner and less sweet. I still have to push it down but it's much easier because I only have to have 3. 21 grams of protein in unjury...another 13 with the fairlife milk. Tomm I get to start pureed stage hopefully after a phone call with the nurse. I'm 10 days out.

I remember the day I got on the scale and it said 402... I was hovering around 380 for a few years For some reason, i was shocked.. it had never occured to me that I would hit 400. I starting to cry tears that fell outta my eyes automatically no matter how i tried to stop and was wiping them off.. I wasnt 400 for very long.. But I was 350 for like 10 years... so i really wanna be under 300 the most. I recal being 14-15 yrs old and never even thinking that I would ever weigh 200 pounds... thats a hoot

Often, especially early on in a bandster's journey, they will post, frustrated by a stall or small gain...here's an explanation of why this happens: Our bodies use glycogen for short term energy storage. Glycogen is not very soluble, but it is stored in our muscles for quick energy -- one pound of glycogen requires 4 lbs of Water to keep it soluble, and the average glycogen storage capacity is about 2 lbs. So, when you are not getting in enough food, your body turns first to stored glycogen, which is easy to break down for energy. And when you use up 2 lbs of glycogen, you also lose 8 lbs of water that was used to store it -- voila -- the "easy" 10 lbs that most people lose in the first week of a diet. As you stay in caloric deficit, however, your body starts to realize that this is not a short term problem. You start mobilizing fat from your adipose tissue and burning fat for energy. But your body also realizes that fat can't be used for short bursts of energy -- like, to outrun a sabertooth tiger. So, it starts converting some of the fat into glycogen, and rebuilding the glycogen stores. And as it puts back the 2 lbs of glycogen into the muscle, 8 lbs of water has to be stored with it to keep it soluble. So, even though you might still be LOSING energy content to your body, your weight will not go down or you might even GAIN for a while as you retain water to dissolve the glycogen that is being reformed and stored.

I totally understand what you are saying. I have decided to get the sleeve, but only because I know that my health outweighs my vanity. I am 5'10 314, with a very shapely body and a small stomach. No one ever thinks that I am over 300lbs, and not many feel my pain of being over 300lbs. I tore my achilles tendon in November and have heel spurs, knee and back pain. I cannot climb more than 2 flights without losing my breath and feeling lightheaded. I can no longer wear high heels for longer than 10 minutes without feeling immense pain. I don't like dancing anymore because I start sweating profusely (which my doctor claims is due to my weight). My father had diabetes before dying and my mother has high blood pressure and cholesterol in additon to severe arthritis. BUT I AM SEXY AS HELL! LOL Not going to get into it much, but I have been to nude beaches and nudist resorts and have no problem being nude. I see a beautiful woman that has some "slight" imperfections in my mirror each morning. I am worried that my skin and breasts will sag and that I will hate looking at myself. I worry that my slight insecurities will turn into major insecurities preventing me from being happy and thus sabotoging my journey. I will be paying out of my pocket and worry that I will not have the funds available in 2-3 years to have plasitc surgery. I am having the surgery - my mind is made up. My health is more important especially since I have 2 children that depends on me to be there. Write it down, what you feel are the advantages and disadvantages of the surgery. I know you will make the right decision for yourself.

I've visited this wensite a few times over the past few months. Mostly looking for info and thoughts and support and everything inbetween. I never signed up, but I did today. My surgery is scheduled for the 26th of this month. As in next week. As in 6 days. I have been so sure of everything I was doing. So confident, and right now I am scared out of my mind. I am so worreid about complications and dying on the table. Not waking up. I'm worried that the surgery is going to go wrong and I am gonna be using a feeding tube for the rest of my life. I'm wondering if I should back out and get my $2000 co-pay back and really work hard on regular excerise and eating right (which never worked before for any decent length of time). I have a baby at home, well a toddler. I'm doing this surgery for her. So I can be a healthy fit mom. So I can run around with her and not be easily winded. So I can show her what being healthy is all about and what to eat and do to live a long healthy life. I want to be a good example. I want to be a better wife. I want to be more comfortable in sexual situations. My God I have been with my husband for 12 years. Married for 5 on 10/5/12. Why do I shudder when he touches my stomach!?!?! I'm one week into my liquid diet, which is so confusing. I always feel like I'm doing it wrong. Which I would be lying if I said I did it by the book, but over all I am proud of myself. I quit smoking on 9/3 started a liquid diet on 9/12 and today I just drastically cut down on my coffee intake. My liquid diet consists of full liquids. So I'm allowed to have cream soups and cottage cheese and farina. I'm allowed yogurt also. I've lost 10lbs this week. I spoke to my bariatic coordinator about an employee party that was suppose to take place tomorrow but was postponed to next week. I wanted to know if it would be okay to eat a piece of chicken. Not that I wanted to cheat but I wanted to know. She said yes, but to chew it til it was paste and then swallow it. She said the issue is I should not be producing stool. Well, I am. Not alot of course and nothing like before but I still am and I told her that and she said everything is fine. So it brings me to the question of whether or not this diet is 100% neccessary. You can shrink your liver by cutting out carbs and sugars, you don't have to go to straight liquids. So why am I not suppose to be pooping, or why do I need to avoid producing it???? Does anyone know? And cottage cheese isn't a liquid so wouldn't that come out a solid??? Very confusing to me. Any advice anyone has and words of encouragement and info on the pre-surgery diet would be so nice and helpful!

@@erp You are gorgeous! You took 10-20 years off your face! OMG

Just lovely! You look so happy and healthy. My surgery is 10/14/16 and you certainly are an inspiration. Thank you!

I have posted this elsewhere but my former surgeon and his partner took over a retiring bariatric surgeon's practice (they are general surgeon, too, in addition to getting into WLS) and I think they wanted to use up old inventory before it expired - and that included the old 4cc bands. They have a sterility expiration date. My current doctor said the same thing you did that the 4cc band is harder to fill - it can take micro amounts of fill. My idiot former surgeon gave me 2cc's and then 1cc for a total of 3cc's - and I couldn't imagine why I was having so many problems with 3cc's in a 10 cc band - because that is the size band he told me I had. Another of many reasons why I left him and found a competent doctor. Thanks, again.

It's the funniest thing to see this because just in the last few weeks, I've been itching for a taste of soda! I am also down to a size 8/10 from a 22/24. Wonder if there is something about this point in the weight loss? I don't think I'm ever going to break down and buy a soda any time soon. I'm betting my memory of how good it was will not match how it tastes now. Not to mention knowing that there is really very little natural of anything in them. Empty calories, artificial sweeteners, chemical dyes and colorings. Not even sure if the Water they use is filtered for the bad stuff! I don't think the cringe that goes up my spine thinking of what's in soda will override whatever this craving is... I would advise you or anyone looking to drink soda, energy drinks, etc. to please consider other options. Most of the time our body is just dehydrated and only needs water. Is it really worth it? Maybe try adding some fruit juice to a fizzy water, see if that does it?

The best part of yesterday was when I walked into my aunts house who has also been my best friend since I was 10. She married my uncle later on & also became my aunt... lol... anyway when I got to her house she looked at me & said " oh my god... I did not recognize you... you look like a completely different person" it had been about a month since I seen her last.made me feel good! Still not use to the attention & compliments I have started to get though. I still see the 321 lb me & I do not notice the 64 lb loss yet when I look in the mirror. Sorry I am rambling now. Glad everyone enjoyed their thanksgiving & everyone looks fantastic!!!

Hello all! My lunch date went great. Very cool Parents, I kept my meal simple and had a quiche with Soup... Before I started my liquid diet I was around 275... This morning I was 268.8. Sugar cravings still hit. I ate 10 smarties (Canadian) worth 50 calories today . I am only human! At least it wasn't an entire box right? I'm still feeling pretty tired... Hoping this passes soon and energy starts increasing again. How's everyone else doing this week?

The problem is not with weighing oneself every day-- the problem is with freaking out over normal weight fluctuations I weigh daily and track my weight on a dry erase calendar I have hanging in my bathroom closet. This is my general pattern of loss-- up and down in a 1-1.5lb range for a week, then a day where I see a new low number. Then bounce back up slightly for a couple days (but the bounce up is to a lower number now), then a new lower number. I consider the "down bounces" a weight loss but I only count full lbs down (so I've been weighing at 193.4, but I count that as 194 until I see 193.0 or below). I do not consider up bounces within the 1-1.5 lb range gain-- because I know after tracking like this for 6 months that they aren't really. This is my pattern and I have steadily lost 70 lbs like this in 6 months. I'm averaging about 10 lbs a month, with many more "bounce up" days than bounce down days. That's just normal. If you expect it, it isn't upsetting. I know with others it absolutely drives them crazy to see that bouncing up and down, so they don't weigh more than once a week. If weighing every day is bothering you, give that a try.

Thanks for posting this thread as we all need the motivation. I have a theme this month: March is a Verb. In otherwise, time to get marching! I am working out 80 minutes 4-5 times a week and really need to make sure I am doing something every single day, or even doubling up some on the days when I have a workout. So, my goals: 1) Get back down to the basement for sporadic 10-20 minutes on the treadmill even on days when I've already worked out 2) Any day that is not too cold call a friend to walk at the lake. 3) Check out the pool at parents' retirement facility. No one uses it and getting a little swimming in would be a great thing. Can start slowly. 4) Do PT exercises with my husband -- they are great for me, too (working with weights). 5) Keeping drinking lots of my drink (32 ounce glass bottle filled 3/4 way with Water, then cranberry juice unsweetened, aloe vera and magnesium). Get in 2-3 of these a day.

This is the new standard. So many people end up not paying their hospital bill that now the hospital wants what they expect your portion to be, up front. When I saw the title, I thought you meant you had to pay 100% up front, not your portion. I was all ready to tell you how to file a complaint about that. But paying your portion up front is to be expected these days. The lab I go to now has the same policy. They told me when I went in yesterday that they expected my portion of the bill to be $19, and they took my credit card info. In their case, it's not charged until after insurance processes.

40 in August, from the biggest little state in the Union! Rhode Island, what are the chances?! Ha ha, Will be banded Sept 22nd 2010, 2 weeks. I am a sucessful single mom of a great 10 year old boy! Cheers!

I'm 31 from Brandon, MS. I was banded on 10/20/2010. I am just looking for friends and if that turns into something more great!!..private message me if your interested!

i may be around 8 or 10 ounces a day currently and its pretty painful swallowing although ive had nothing come up. i called the doctor on day 1 post op and explained my issues. he said it just may be swelling and my opening is very small but he also mentioned the band was pretty snug and if i cant get more fluids in by the end of the weekend, they may have to give me fluids via IV or worst cas, surgery again to place a larger band! im freaking out a bit because surgery is the last thing on my mind. im still very very sore and not moving around very well at all. i wasnt planning on missing much work, but at this rate, im in big trouble. any words of encouragement or advice?

I am looking forward to kicking myself in the butt. I will miss the fried chicken, the ribs and the nice pork chops...I looked in my picture album....I gained on an average of 10 pounds per year. At age 39 in this picture of me--I was 176.....I actually was shocked to know I had a good weight.....I was shy to ake off my shirt during that time--at 175....Lord was I stupid... Now--if I am blessed and work hard to get back to that elusive 165-175...:eek: :hungry: My shirt is going to come off a lot--hahahahahahaaha....I would love to go back to the Coast of Mississippi--and show the ex---but she'll say the stupid things---"Oh Lee--you look sooo sick":omg:

I was actually sleeved on August13th. So far no issues at all. I have had no pain or anything. I actually played golf and walked the course 10 days out. As far as liquids no problems at all. Now trying to eat soft foods I just cannot eat that much. 5to 6 oz top's.I found some great info as far as drinking and eating. I guess the issue is if you drink while eating the food leaves your sleeve faster and keeps you less full longer. That is the reason for not drinking during and after eating. Makes sense to me...

I don't feel hungry. But I do feel weak. Im working on getting in my Protein and fluids. I'm doing okay with the liquid diet, Im just tired of it already and have never liked shakes and smoothies,... so I sometimes just don't have them. I freee them into pops though and I can have them that way. It's a battle any way you slice it, as we all know. My doctor was never specific on any of this, but it is really bothering me. im supposed to sip all day between meals, but if I can only hold a few oz, how is that okay? also, when do I stop eating? I can eat about 4 oz before I really just dont want any more. i am not full sick, or sick at all, i just cant bare to take another bite. is that mental? is that my body telling me im full without a physical sign but a mental one? there are no signs that i am full, but at about 4 oz, i just shut off i guess? head hunger is hard. i had a few bites of cooked ricotta cheese and sauce from the lasagna i made today. (i'm on fll liquids and doc okayed easing into soft foods, so technically not a "cheat" but i feel guilty) it was yummy, but i feel guilty. when am i supposed to eat? i wasnt given a meal plan. i dont want to eat a "meal" because i want something to do. i need a schedule but i dont know what is appropriate. the nutritionist didnt give me a post op example for the 600 calorie diet, only the 1 year post op diet. for example today i ate 2 oz of a Protein shake, then three hours later, 4 oz of yogurt, then two hours later, 2 oz of sauce, then three hours later 3 oz of Soup. it was about 250 calories. obviously that is not 600-800 a day. am i supposed to eat more?

I had my surgery 8/19 and I cant drink cold or hot.. pretty much room temp for me right now. I have gone through almost every glass in my house until I found a glass that allows me to sip not gulp.. the gulping pain is gas/air. also dont be scared to ask a pharmacist for some medicine cups and drink out of them until you get the hang of it. I wasnt getting enough liquid so found that chicken noodle(less) Soup is it for me 8oz,. I have it for lunch ( i kept the veggies but ditched the noodles) I add one scoop of Protein powder unflavored to it. It takes me several hours to get through it but its liquid and protein.. I struggled after surgery with the Protein shakes. This week I have had three days stomach pain free.. remember you are healing inside

Im 5 years in Oct and when i had the endoscopy before surgery i had a slight hiatal hernia.ive always suffered from heartburn on and off but everything was ok.until 3 months ago when i had my 3rd endoscopy and was told i had an ulcer(my biggest fear with this surgery) and my hernia is alot worse.so i was put on carafate for 3 months and had my hiatal hernia repaired 5 days.another endoscopy was done right before surgery and showed ulcer healed but i had a massive amount of scar tissue from acids in my stomach.also my stomach is still very irritated and i just got back from check up today and i have to be on pureed foods for 4 more weeks and still on protonix for 2 months more(ive been on protonix since my sleeve,5yrs!)also have to get another endoscopy in 6 weeks!omgg,this acid needs to stop already!anyone else been down this road??? 10/6/2014-214lbs 7/15/2019-149lbs Sent from my SM-G960U using BariatricPal mobile app

Surgery 9/17 weight 204, size 16 Weight today 167 , size 10

Help Center -Department of Managed Care This I my appeal letter to ask that you reconsider and approve the Sleeve Gastrectomy Weight Loss Surgery that was denied by Anthem Blue Cross because they consider the procedure investigational. I believe this surgery is exactly the tool I need to improve my health and the quality of the rest of my life. I have been told by several of Anthem Blue Cross customer service representatives that 43775 is a covered procedure and that as long as my HMO approved they would pay for the surgery. This is not what I am being told now. I have been getting the runaround on this for two months. I received a letter from my HMO dated 2/6/10(copy enclosed) stating this is not a denial of service but Anthem considers this procedure experimental and has to go to the Utilization Dept for a decision. The number to call this department was on the letter. I called this Dept. a minimum of 5 times and was told they don’t know what I am talking about, this dept. doesn’t handle HMO. So I call my HMO and they say “oh you have to appeal” so I send my appeal letter to Anthem on 2/16 and wait the 30 days for a decision. On the 28th day they inform me that I cannot appeal because I haven’t been denied, oh and the people in the Utilization Dept. don’t know that their department handles this?? So they send it back to the Utilization Dept and now I have officially been denied. This part of this process has taken two months, very frustrating. I. PATIENT BACKGROUND My name is Jeani Xxxxxxx and I am insured under group plan xxxxxxxxxx. My member ID # xxxxxxxxxxxxx. I am now 59 years old. I am 5/5 tall and at this time I weigh 233 lbs. I am seeking approval for weight loss surgery. I have been overweight to one degree or another since I was a young child and was advised by my pediatrician to diet at age 10. I have made numerous efforts at weight loss throughout my teenage years and adult life. I dieted frequently as a teenager and young adult. Numerous times I have lost 40-80 pounds or more but eventually the weight returns. Weight loss programs I tried include juice fasts, traditional calorie counting on quite a few occasions, Weight Watchers, Slim Fast, Nurti-system, the Atkins diet, Cabbage soup, Mayo Clinic diet, the Zone, gym membership, lap swimming, weight training, water aerobics, walking programs, various buddy-system diets and individual, self hypnosis, ”Think yourself Thin” “ Think yourself Thin Automatically, tape you listen to in the car” Dexatrim, Metabalite, Hoodia, Green Tea Extract, and numerous other fad diets. In all cases I lost weight but each time the weight crept back, usually with a little more. Eventually I realized that traditional dieting seemed to actually cause weight gain due to increased hunger that seems to occur after significant weight loss. I believe science is only now beginning to understand the reasons for this phenomenon which is consistently reported by clinically obese people. Studies also show that genetics plays a larger role than once thought and there are morbidly obese people in my family as well as slim people. My co-morbidities include high blood pressure, high triglycerides, low good cholesterol, have had abnormal EKGs, borderline diabetes, and osteoarthritis in my hip, which my doctor said weight loss would help significantly. I have also had sever back pain most of my life. I take hydrochlorothiazide and verapamil for high blood pressure which is effective. I take medicine, Niacin for high triglycerides. I have a family history of cancer as well as strokes, heart disease and severe arthritis. I take nabumetone almost daily and ibuprofen to help with severe leg pain related to arthritis in my hip. I have taken ibuprofin for back pain that i have had most of my life even when I was not overweight. I believe I will need NSAIDS even after WLS which is why I need the sleeve as this is the only WLS that you can still take anti-inflammatory medications. I buy over the counter ibuprofen as I can get 500-200mg pills for $10.00 which last over 6 months, whereas when getting prescription I only get 30 -800 milligrams for a co-payment of $10 which only last a month. My excess weight and other health issues makes everyday activities difficult including housework, shopping, standing, walking significant distances, working and recreation. It effectively makes my world smaller limiting the number of things I can do each day. I have lived with obesity for years and strongly wish to change this aspect of my life. I fear the consequences of my high triglycerides especially considering the family history i have of heart disease. Many members of my family died of heart attack and stroke. I was stunned to learn that my weight is in the obese category but heartened to learn of this newer treatment with fewer side effects and shorter recovery. I am highly motivated to succeed with VSG and understand that food intake will be significantly limited for the rest of my life and that I must continue to exercise to be successful. Before I found out about the arthritis, which is the result of a subtle fracture at some point in my life that affected the curvature and angle of my right hip bone (this was found by an MRI that was done after pain medication didn’t help and physical therapy made the pain worst), I used to walk a minimum of 30-60 minutes a day at least 5 days a week. Since this pain in my leg as a result of the hip arthritis I no longer can do that and I am afraid that the weight will just continue to creep up on me. My particular problem is in volume eating. I eat good food, lots of chicken and turkey, lots of fruits and vegetables, the thing is I am always hungry and I eat until I am full. Having a smaller stomach and feeling full sooner seems like exactly the kind of help I need. I had given up on traditional dieting as it always resulted in failure and am pleased to have found the VSG surgical option which appears to be the only tool offering a realistic possibility of lifelong weight control for me. I believe VSG is the best surgery for me because it offers restriction like the lap-band and the RNY but without the malabsorption of the RNY. The RNY is not an option because I very much need regular doses of nabumetone and ibuprofen for the leg pain related to my hip pain and even once I lose the weight believe I will still need ibuprofen for my back pain which I have suffered with most of my adult life. Tylenol is not effective for me. I am allergic to codeine, vicodin, any pain medication of that type I cannot take. Narcotic pain relievers make my head seem fuzzy but do not help with pain. I have the same concern about the lap band. I also understand that as many as 27 percent of lap band patients require band removal and weight loss is often unsatisfactory (I think the number is even higher now). Most importantly, the VSG removal of a large portion of the stomach removes many of the cells that produce the hormone ghrelin which is known to cause hunger and appetite. The RNY and lap band don’t have this advantage. At age 59 I am concerned about the side effects of the RNY and do not want to spend 6 or more months with dumping syndrome and feeling rotten. I also worry about the ability to take and absorb other medications I might need in the future as I age. The VSG appears to offer the fastest recovery, weight loss similar to the RNY and the least amount of side effects. One recent publication, “The Best Bariatric Operation for Older Patients “ by Drs Lee, Cirangle, Taller, Feng and Jossart, 2005, concludes that “These data suggest that the best bariatric operation for older patients may be the laparoscopic VG because it achieves the greatest weight loss with the shortest operative time and the fewest complications”. I have investigated this procedure very thoroughly including attending support groups and talking with others who have had it. I have completed most of the preoperative testing and strongly believe this is the best procedure for my circumstances II. THE VSG SHOULD NO LONGER BE CONSIDERED INVESTIGATIONAL The only stated reason for denying approval for the VSG is that it is investigational and …” current available medical studies do not show that this service improves health outcomes, is as good as or better than standard alternatives, or shows improvement outside the research setting”. It is respectfully submitted that this conclusion is incorrect. The conclusion ignores the 36 studies now available on the effectiveness of VSG which indicate that excess weight loss is similar to the RNY and that complications from surgery are actually lower than RNY. It also ignores the fact that the VSG is now widely performed and is routine for many bariatric surgeons and has long been performed outside the research setting. Anthem’s policy on Surgery for Clinically Severe Obesity is set forth in a document with an effective date of April 22, 2009. This document reviews the various forms of bariatric surgery and explains when weight loss surgery is considered medically necessary. VSG is excluded from ever being medically necessary because it is designated as investigational and that “…there is insufficient convincing evidence in the peer reviewed medical literature, in terms of safety, to support the use of …sleeve gastrectomy…other than biliopancreatic bypass with duodenal switch, in individuals with clinically severe obesity.”. Nevertheless, the lap band and Realize band procedures are approved as medically necessary in this same document based upon what appears to be two three year studies involving 219 and 352 patients respectively. There is now a considerable body of data and studies supporting the safety and effectiveness of the VSG as a primary procedure for weight loss. The June 2009 Supplement to Bariatric Times reporting on the Second International Consensus Summit on Sleeve Gastrectomy (available at www.bariatrictimes.com) includes 10 papers pertaining to the safety and effectiveness of the VSG presented by leading bariatric surgeons. In Reducing Risk in Bariatric Surgery: Rational for Sleeve Gastrectomy, Dr. Eric J. DeMaria concludes that “A growing body of evidence suggests sleeve gastrectomy may be an appropriate primary bariatric surgical procedure primarily due to low risk and ease of surgical revision when required.” In the paper presented by Drs Jossart and Cirangle, four years of data showed a 68% excess weight loss by VSG patients, a figure not largely different than RNY patients of the same time range. Most significantly, in Debates and Consensus: a Summary by Dr. Michael Gagner, important questions concerning the VSG were debated and conclusions reached by the 400 conference participants. Question 6 was as follows: “Question 6: In your opinion, is there currently enough published data to support the sleeve gastrectomy as a primary procedure to treat morbid obesity on par with adjustable gastric banding and Roux-en-Y gastric bypass? Several groups presented cohorts of patients with follow-up periods of 4 to 8 years the day before. Jossart and colleagues in San Francisco presented eight years’ experience including 1,200 cases, whereas at more than four years, weight loss resulted in a similar curve to gastric bypass. At higher BMI (greater than 55kg/m2) a plateau of nearly 40kg/m2 demanded a second stage, but below a BMI of 55, the operation was terrific. Schauer and colleagues assessed the literature from 35 reports, studied more than 3,000 published sleeve gastrectomy cases, and found an extremely low mortality rate (near 0.12%). Results have shown excellent weight loss and co morbidity reduction that is comparable to or exceeds other bariatric operations and that the sleeve gastrectomy is safe and efficacious. Himpens of Belgium analyzed his patients from 2001 through 2002(sic) to attain six-year follow-up. Sixty-five percent of 46 patients were considered a “success” (%EWL greater than 50 ) at two years. At six years the success rate was maintained at 59 percent. Weiner from Frankfurt and MacMahon of Leeds, who started in 2000, also had similar results. *** Certainly, the audience thought there was enough evidence published to support the sleeve gastrectomy as a primary procedure to treat morbid obesity on par with adjustable gastric banding and Roux-en-Y gastric bypass with a yes vote of 77 percent. This is perhaps the strongest contribution to this second consensus conference.” A review article entitled “Systematic Review of Sleeve Gastrectomy as Staging and Primary Bariatric Procedure” was recently posted on the web site of the American Society of Bariatric and Metabolic Surgeons dated May 26, 2009. The authors are Drs Brethaur and Schaur and Jeffrey Hammel M.S. of the Bariatric and Metabolic Institute of the Cleveland Clinic, Cleveland, Ohio. Thirty-six studies involving 2570 patients who had the VSG procedure were analyzed. Their conclusion was: “From the current evidence, including 36 studies and 2570 patients, LSG is an effective weight loss procedure that can be performed safely as a first stage or primary procedure. From this large volume of case series data, a matched cohort analysis and 2 randomized trials, LSG results in excellent weight loss and co-morbidity reductions that exceeds , or is comparable to, that of other accepted bariatric procedures. The postoperative major complication rates and mortality rates have been acceptably low. Long-term data are limited but the 3- and 5- year follow up data have demonstrated the durability of the SG procedure. “ To date ten thousand patients have had the VSG surgery with good success. Many are going to Mexico or other foreign countries because their insurers refuse to pay for the VSG even though it is less expensive than the RNY procedure, the so called “gold standard” of weight loss surgery which takes several hours and requires a hospital stay of 3 or 4 days. The VSG can be completed in one hour by a skilled surgeon and most patients stay only one night in the hospital. While there is certainly follow up care, the repeated fill and unfill procedures required by gastric banding are unneeded for the VSG. Nutritional supplements are much less of a problem than with the RNY. Many insurance companies are recognizing the value and cost effectiveness of the VSG and have approved the VSG for at least some patients, including BSBC Federal, Tri-west Tri-care Prime, United Healthcare, the Veterans Administration, Aetna, Blue Care Network HMO, Healthnet, Anthem BC of Connecticut, Definity Health/United Healthcare, PPO, Empire Blue Cross Anthem, and UHC. The VSG sleeve gastrectomy is now routinely offered by Kaiser Permanente to all patients that qualify for Weight Loss Surgery and would not do so if this surgery was not proven to work. I don’t think it is fair that if you have five people, one with Kaiser, one with United, one with Aetna, one with Cigna and me with Anthem Blue Cross of California, the other four will be offered the sleeve and I will not. The California Department of Insurance has recognized that VSG is widely accepted by the American Society for Metabolic and Bariatric Surgery as a standard procedure at medical centers for excellence. In Decision #EI09-9645 the physician reviewers reversed the health plan’s denial of the patient’s VSG request and concluded that VSG was the most appropriate option for the patient. The same conclusion was also reached in EI06-5882 though the patient had significantly more co-morbidities. That decision noted the important fact that the VSG is nothing more than the first part of the duodenal switch operation which includes the second step of intestinal modification and as such, the VSG portion has been performed for many years as part of the DS procedure. Some patients have the VSG first as part of a two stage procedure and find that they do not need the second stage. Thus, the VSG is not as new and investigational as Anthem’s conclusions seem to imply. Anthem does cover the DS procedure which includes the VSG as one part. According to an article published in the Detroit Free Press on August 17, 2009, Blue Cross Blue Shield of Michigan, in conjunction with the University of Michigan, has been compiling a large detailed data base on bariatric surgery in order to improve surgical outcomes and provide cost savings. In three years of data collection, it appears that the VSG now accounts for as much as 12% of all bariatric procedures. This percentage indicates that the procedure is far beyond investigational status. This data base indicates that 10,000 VSG procedures are known to have been performed. My Anthem group policy excludes investigational procedures and defines that term as procedures: “ 1) that have progressed to limited use on humans, but which are not generally accepted as proven and effective procedures within the organized medical community; or 2) that do not have final approval from the appropriate governmental regulatory body; or 3) that are not supported by scientific evidence which permits conclusions concerning the effect of the service, drug or device on health outcomes; or 4) that do not improve the health outcome of the patient treated; or 5) that are not as beneficial as any established alternative; or 6) whose results outside the investigational setting cannot be demonstrated or duplicated; or 7) that are not generally approved or used by Physicians in the medical community. It appears that the VSG, based upon the articles cited above, has been performed on thousands of patients, has been accepted by a consensus of participating members of an international conference devoted to this subject, is widely accepted by the ASMBS, does not require FDA or similar government approval, is in fact supported by at least 36 studies analyzed by highly respected physicians, is as effective as the RNY and more effective than gastric banding in terms of percentage of excess weight loss, has fewer complications than the RNY, has as good or better reduction of co morbidities as other procedures, and has results that are similar in studies by both United States and foreign physicians. The VSG therefore no longer falls within the definition of investigational procedures excluded from coverage. The conclusions stated in the previously cited Anthem Policy on Surgery for Clinically Severe Obesity are simply no longer correct and that policy should be updated to include VSG coverage or disregarded. With the VSG patients lose about 68% of excess weight and lower BMI patients like me often do much better. Weight loss will most certainly help my back and hip pain and improve ability to exercise. High triglycerides, high blood pressure, and borderline diabetes are corrected in about 76 percent of WLS cases and I am hoping for this result. It is therefore highly likely that my health will be improved by this procedure and I respectfully ask for your reversal of this denial. I am a mother and soon to be a Grandmother and I want to improve the quality of my life so that I will be healthier and able to help raise my grandchildren and be able to take an active role in their life.Thank you for your review of this matter. I greatly appreciate the fact that the state of California has a procedure to help insured patients who find themselves in disagreement with their insurance companies. I strongly believe this decision will greatly affect the quality of the rest of my life. Thank you for your time. I eagerly await your decision regarding this. I can be reached as indicated below if further information is needed. Enclosed is a copy of my denial letter from Anthem Blue Cross My HMO is Healthcare Partners Primary Care Provider is xxxxxxxxxxxxx Gastric Surgeon xxxxxxxxxxxxx Sports Medicine xxxxxxxxxxxx who ordered MRI and diagnosed arthritis Cardiologist xxxxxxxxxxxxx did my last EKG and stress test All these doctors agree Weight Loss Surgery is a good option for me. Respectfully yours, Jeani Anderson xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx (xxx) xxx-xxxx Work info: xxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx xxxxxxxxxxx CA 91101 (xxx)xxx-xxxx ext. 244

SOOOOOO I was supposed to start my 26 day preopreative diet yesterday.. Optifast.. HOWEVER... when I weighed in at the doctors, my BMI was 41.6, I have about 10 lbs to play with and my particular insurance can deny payment below 40.... SO my preop diet will be 4 days of optifast before surgery, that is it! SCORE, I am so excited. Don't get me wrong I was looking forward to the weight loss and starting yesterday but it is going to save me almost 500.00!!! I am not going to complain about that So excited for everyone... here we go! I am 25 days away from my new life!