Hi Everyone! I just discovered this site a few days ago and have been reading like crazy. Lots of great information.

I have begun the process of getting approved for surgery in my hometown where there is a Bariatric Center of Excellence with excellent surgeons. My insurance will cover gastric bypass but will not cover VSG. I actually didn't even know about VSG until I started reading about it on another site last week. VSG feels like the perfect fit and addresses my most pressing concerns about having bypass surgery: what seems like mutilation of the natural process of digesting and absorbing with the bypass, Vitamin deficiencies, not being able to take NSAID's, dumping and vomiting (I've only vomited 10 or so times in my life and HATE it). I want the VSG.

I have an appointment with my surgeon in a couple of days and feel sure he is going to push for the bypass. While they do VSG's, they require a BMI of 50 or greater. Mine is 42. So, I am almost positive they won't do a VSG on me.

I have been researching VSG surgery in Mexico and feel very drawn to Dr. Aceves in Mexicali, Mexico (interestingly, about three years ago I was doing a web search on lapbanding and came across his site and really liked what I read). I have the ability to self-pay and am considering scheduling the surgery with him.

Here is my dilemma: do I tell my current bariatric surgeon of these plans? I'd like his support but I feel like he will try to talk me out of it.

Thanks for letting me process!

Lisa

It seems odd they would require a higher bmi for sleeve than bypass. I would think it would be the other way around, oh well.

I was in the same situation. Only it was because my insurance changed. I had just started the process. I did not tell the surgeon and just did not go back. It was made clear when I mentioned something to the nurse that they only follow their own patients or patients who have to relocate to the area. My PCP also told me that the bariatric docs "would not touch me if something went wrong" because of liability. I am followed by my PCP and by Dr. Aceves by phone and email.

You are not likely to get his support. Some insurance companies require a BMI of 50 for the VSG because they consider it experimental.

Lisa, most insurance co have that bmi requirement is usually for the DS not the stand alone part of that procedure the sleeve. they don't pay for the sleeve here either, and no one knows about it, my wls has only done one, there is not need to tell your surgeon until you have made the decision to go and then it is up to you if you would like them to support you when you are back home. why not try to get it appealed through the insurance co here?

Thanks for the feedback!

My insurance will not cover VSG's for any patient, even one with a 50+ BMI, as the VSG is considered "experimental." It may be that they will in the future, as it seems to be a trend that insurance companies are seeing the VSG as a great tool for WL. I'm not sure when that might happen, though.

exactly, they say that the sleeve is experimental, the 50 bmi requriement is a requirement of DS and not the sleeve as they have no requiremnts for that as they consider it investigational, i too agree since 2 major insurance co aetna and cigna are covering it, it will only be a matter of time till others jump on, like they did with the lap band-depending on how long that is, i may be joining you overseas....

hi, my bmi was about 38 and my insurance carrier denied the sleeve saying it is investigational,,, i have arthritis and a bad back and will always need NSAIDS so i appealed,,in CA you can request an independent medical review and 3 independent doctors review your case,, i won with a vote of 2-1 if you want to see a copy of my appeal letter check out my blog,,, best of luck,, it took a couple of months but i had my sleeve 4 weeks ago and i couldn't be happier,, lots of people are winning on appeal,, best of luck to you jeani

delawaregal do you go to any support classes on the area? I am not far from you and am looking to go to some that have sleeve people.

Thanks

Hi Jeani,

Wow, I just read your appeal letter. Nice! I'm glad you won it and have your sleeve. I will bring up appealing to the surgeon when I meet with him on Wednesday. Our health issues are similar, although I don't have arthritis. I do have a chronic back problem and have no relief from any other OTC pain medication except ibuprofen. I can't imagine not being able to take ibuprofen--I've tried Tylenol, etc. and I might as well be eating candy.

I'm curious if my BCBS plan will even consider an appeal, though. I just assumed if they don't pay for VGS, they won't consider it, period. It gives me hope, as it would be so much easier to have the surgery done in my own backyard and have all the follow-up care available and covered.

I am not sure about the insurance portion, I was self pay and went to Aceves, you are correct in being drawn to him, he is excellent!

Best of luck to you and in your decision!

hi,, every state is different but i'm fairly sure they all have a system set up if you don't aggree with your carrier's decision you can request that they be overturned,,if BCBS doesn't provide this information to you contact your state's insurance commissioner's office,, when they use investigational you can fight it since you need the NSAIDs that is why i believe i won,, best of luck to you,, its nce to get it done here at home and have after care covered,, take care jeani

I think the reason that the sleeve requires a higher bmi is because when I read about the sleeve on medical websites, it is an operation that patients with higher bmi's go through before a gastric bypass, i.e., they don't think the bypass is safe at such a high bmi; they think the sleeve is safer. Once the person loses enough weight, then they can have the bypass.

that was the thinking,, when they were doing the ds, now they have found that as a stand alone procedure for lighterweights that it very successful,, the insurance companies just need to catch up,,, thankfully they are starting to change their way of thinking,, the rest need to catch up,,, thank God i won my appeal and i got the sleeve 100% covered by my insurance, thanks to an independent medical review,,take care

The investigational claim is pretty easy to fight. My local BCBS gave it up on the first round of appeal (then went on to fight my revision because I hadn't regained up to a 35 BMI yet, then when I did went on to fight because there aren't studies showing a VSG is an appropriate revision procedure).

You can see the information I used on my blog that got them off the investigational kick. I loved Dr. Aceves but it's nice to get insurance coverage for the procedure and any possible complications if you can. But you probably also want a surgeon with lots of sleeve experience too if you can.

Britt

My Revision Appeal: From Lap Band to VSG: VSG: No Longer Investigational

I have bcbs also, they are the worse for getting an appeals overturned and they are notorious for that crap, deny one reason, overturn that, then deny on another reason, then deny some other reason and deny that, they are really really awful. it is at best deplorable

Thanks everyone, for the information and the possibility that I can appeal and perhaps win. I am excited and anxious to meet with the surgeon in a couple of days to find out if he will support the decision to request a VSG in his letter to BCBS. I do remember him saying at the informational meeting that he believed in the future, the VSG would become the gold standard of bariatric surgery.

I am a pre-anticipator (just made that up!) and am already mentally skipping ahead to either a "no" or a long battle with no assured outcome regarding insurance coverage; meanwhile, I feel strongly that I want to proceed with the surgery sooner rather than later. My weight continues to creep skyward (42.2 BMI) and I feel strongly that by next year I will have developed Type II Diabetes (I'm two points shy of it according to March blood work).

When I think about traveling to Mexico to have the surgery, I don't worry about the surgery or going out of plan but about follow-up care afterwards and the possible attitude of my PCP (who does not know I am pursuing surgery--it's not required that I meet with her to get approval so I went straight to the bariatric center). I don't know what type of follow up is involved after the surgery. Do stitches need to be removed? I guess I'm afraid of being judged by my PCP. And at this point I'm making it all up in my head. LOL.

For those of you who have had the surgery done outside of the USA, what has been your experience with your local PCP?

Thanks!