Advice from the experts please? :-)

[Brianna_Nicole 4]

Hello everyone! :-) This is my first post here. I was recommended to check out this site after posting on OH.

Some info about me: I'm 25 years old, female, 5 feet tall and 263 pounds. I want the DS surgery. So far I've had my surgeon consultation and first dietitian appointment. I have all my other evaluations scheduled in the next month.

My first issue I'm hoping for advice with: I went to my consult adamant that I want the DS surgery. Unfortunately I am NOT good at standing up for myself or disagreeing with doctors. When the surgeon asked what surgery I want, I said DS and he basically said that I do qualify at my BMI, but he would recommend I do the sleeve because I'm young and have a long time ahead of me to deal with the side effects and deficiencies that come with the DS. He said that if I'm not successful I can always have the 2nd part done and convert to a DS. He asked me what I thought about that and because of my shyness I said okay to the sleeve. After coming home and doing even more research, I'm even more adamant that I want the DS for many reasons:

1. I want to lose 120 pounds and KEEP IT OFF. The DS has the best results and least chances of regain, which I have a long history of. It looks like the average weight I can expect to lose with the DS is at least 90-100 pounds, while with the gastric sleeve I would probably only lose about 60. While losing 60 pounds would of course be wonderful, I would rather have the surgery that can take me to my total goal.

2. I have heard that the DS lets you eat the most normally.

3. I want to have the best possible surgery now, one time. I don't want to have to go through surgery again.

4. On the same note, getting a second surgery approved will be extremely difficult and probably denied, so if I don't lose enough weight or if I gain a lot back, I will have to self pay which I cannot afford.

5. Taking Vitamins and committing to blood work and follow-ups is not a problem to me. I look at it this way - I can have this surgery, take daily Vitamins and go to the doctor regularly to check levels; OR, I can not have the surgery and continue to have weight issues, take daily medicines for co-morbidities and go to the doctor regularly for my health problems.

So, I plan to call the office today and let them know I have changed my mind and want the DS. I'm worried that my Dr. will be offended or something, because I have known a lot of doctors that can be arrogant and hate being questioned. At my consultation he was extremely nice and didn't give me any indication that he was that type of person, but I'm still nervous!

So my question is: what do you recommend I say to the doctor to support why I disagree and want the DS? If for some reason he refuses to do it for me, can I transfer the evaluations I've done to another practice/surgeon without having to start all over?

Next issue: I had my first dietitian appointment on Monday and I'm very worried that he doesn't know and understand my insurance requirements. My Cigna plan requires 3 months (so 4 consecutive monthly appointments) of a physician or dietitian supervised weight loss program. When he mentioned I would be seeing him one more time, I told him that my insurance requires 3 months of visits. He went and got a packet with a description of the requirements for all the different insurance companies and said I was right about that. He then said that I could just see my PCP for some of the appointments. I said I want to do the 4 appointments all with him because it is supposed to be with the same doctor and I do not want to do ANYTHING that could get me denied. He said that was fine and we could meet monthly. Another concern of mine is that my monthly weight loss program requires documentation of my weight, dietary program and physical activity. He recorded my weight and taught me about the 1200 calorie diet plan he is prescribing for me and gave me papers with all the details and recommendations, and he taught me about the Protein and other diet requirements for after my surgery. The appointment was very informative and helpful, but we never touched on a physical activity plan at all. Maybe I am being paranoid, but I'm very worried about problems with insurance after the horror stories I've seen in the forums. I want to make sure every detail is perfectly followed.

So what I was thinking of doing is seeing my PCP every month on top of the dietitian appointments, just in case it's not done correctly by the dietitian. My PCP is great and strongly supports my surgery. I'm positive he would do the weight loss program with me and follow all my requirements. Do you guys think this is a good idea? Could seeing both the doctor and dietitian at the same time for the weight loss program possibly be a problem for any reason you can think of?

Okay, now one more topic! I am really sorry for this incredibly long post, I just have so many questions and concerns.

I have checked and confirmed my bariatric surgery coverage in a few ways. I call the Cigna customer service line twice to confirm that my specific plan covers weight loss surgery and both times was told yes, it is covered. But I just don't trust the people on the phone to always be correct. I also signed into my account on the Cigna website and used the cost estimator for my plan, and it said that I can expect to pay a $300 co-pay for bariatric surgery. Lastly I read the coverage booklet posted by the employer providing the plan. The only mention of bariatric surgery is in the exclusions section, but this is what it says: "Payment for the following is specifically excluded from this plan: .... • for medical and surgical services intended primarily for the treatment or control of obesity. However, treatment of clinically severe obesity, as defined by the body mass index (BMI) classifications of the National Heart, Lung and Blood Institute guideline is covered if the services are demonstrated, through peer-reviewed medical literature and scientifically based guidelines, to be safe and effective for treatment of the condition."

Is it just me or is that a bit confusing? I'm thinking this means that the plan does not cover any obesity treatment for those who do not have "clinically severe obesity". A BMI over 40 or between 35-39.9 with co-morbidities is defined as clinically severe obesity. So I definitely meet this requirement with a BMI of about 52. I'm also thinking that the last part about treatments that are peer reviewed and scientifically shown to be safe and effective means that the 5 procedures covered in the Cigna bariatric surgery coverage policy are all covered (gastric Bypass, gastric banding, RNY, vertical banded gastroplasty and BPD/DS for those with BMI over 50).

I just find it odd that weight loss surgery is ONLY mentioned in the exclusions section. This booklet may be outdated - the "effective date" in the beginning is February 2009.

Well, if you made it through this post, I appreciate it and applaud your patience! :-) Thanks so much for any advice or insights you can provide.

[toastedink 115]

Your reasons are why I chose the DS as my surgery.

It's your body. Tell him you want the DS. I would also go over your reasons with him. Show him you have done your research.

I also have Cigna. And they approved me no problem. But I would call them and discuss it. And make sure you note the times and who you spoke with.

Edited January 15, 2015 by toastedink

[Stevehud 1,790]

ill only say this, the difference between the VSG and the DS is negligible. The routines you have to adhere to are almost the same as well. But I am curious why you think you can only lose 60 pounds on a VSG? the weight loss doesnt stop at a certain point. there are many sleevers who weighed more than you and lost a lot more than what you want to lose. Heck there are those who weighed less and lost more. The key is with either surgery YOU have to make the lifestyle change the surgery only helps you make those changes , sure at first its because you have to, but you are supposed to learn as you lose to change your eating habits and lifestyle, and go to the gym and eat healthy.

Personally i chose the sleeve due to the lower complications, easier surgery and recovery, and the much lower risk of dumping syndrome and malabsorption problems. But whatever helps you is great I am slated to lose over 170 pounds from the sleeve.

Either way you choose, you may want to do more research on the after routines and what YOU have to do for yourself after either surgery before you commit.

Good luck wih your decision and with your weight loss.

Either way, you can do it!

Edited January 15, 2015 by Stevehud

[Postop 404]

…I have heard that the DS lets you eat the most normally.

With the DS you can eat all the Protein you want.

...getting a second surgery approved will be extremely difficult and probably denied, so if I don't lose enough weight or if I gain a lot back, I will have to self pay which I cannot afford...

I know some surgeons feel a 2 step DS is safer. If that's the reason, I can't argue w/the surgeon. However, if you want a 1 step and it's safe; I'd push for it (I had a 1 step). You're reasoning is sound. If you get too thin, ins. cos. are reluctant to approve the 2nd stage of the DS.

...Taking Vitamins and committing to blood work and follow-ups is not a problem to me...

I had to really push for the DS. I was told the RNY was enough for me (this was before the sleeve alone became so popular). I didn't go back to that surgeon. Another said basically the same thing. I brought in my accordion folder w/all my DS research, etc. It impressed him enough that he agreed I would do well with it and be compliant.

Does it have to be that surgeon? Can you come to NYC? Those records are yours. You should be able to get them and/or have a new doctor get them.

Wish I could help re: the weight loss preop program; however, it wasn't done when I had my DS almost 10 years ago. If you don't find the answers you need here, I've PM'd you with another site that has a lot of DSers. They can help you out with this and about your policy. There's especially one girl who knows a lot about insurance.

Edited January 15, 2015 by Postop

[Djmohr 6,965]

I would be careful about assuming the average weight loss is where you will land. The reality is this is a tool and the most critical piece is making the lifestyle changes to keep the tool functioning properly.

Regardless of what surgery you end up having you will have to make the changes to get the maximum effect for that surgery.

I am not sure about DS but I do know that the first year is the most important for RNY. My doctors office actually spends a lot of time teaching what is most important to get the maximum effect from your surgery. If you do that, you will not be average.

Good luck to you in whatever you choose to do.

[samuelsmom 670]

@

1) 2009 is ancient for an insurance manual. However, it sounds like you should be covered.

2) The dietitian's visits are enough as your weight will be checked each time. No need to see your PCP unless there is another issue. That being said, if your PCP will be the most helpful- then go ahead. You want to surround yourself with caregivers who will give you the best support.

3) Surgery choice: I can understand your physician's recommendation for the sleeve. There is no reason to expect that you will not lose weight or that you will regain it. that is possible with each surgery. DS requires 3 + hours under anesthesia raising the liklihood of complications. Quite a few surgeons routinely do a sleeve first to limit the amount of anesthesia at one time. As you may know, that is how the sleeve got it's start- it was used as the first part of the DS and so many patients did well and never needed part

4) You seem very motivated. With that level of motivation you sound like someone who would do well with the surgeon's recommendation. You also mentioned you are ok with supplements and labs, however, the problem is malabsorption syndromes and you are very young. I am a strong believer in patient choice, however, as a nurse, and bariatric patient, I think your surgeon's advice was very wise.

Good Luck in your weight loss journey!

Edited January 16, 2015 by samuelsmom

[Taraashley04 3]

I am also having the same concerns as you in deciding on a surgery. I need to lose 125 pounds and my doctor also recommended the sleeve instead of the switch because I'm 28 and want to have children very soon. But he said I would only lose 60 pounds also with the sleeve and i could come back and do the switch after I'm done having kids. I don't want to have to have another surgery, I want to do it right the first time. I've already had the lap band 3 years ago and am now getting a revision, so a 3rd surgery for me is not an option. My man in concern is having children right after the switch.

[Postop 404]

...My man in concern is having children right after the switch...

They like you to wait at least 18 mos.

[gowalking 10,790]

Hi there. Your stats are similar to mine. I am also five feet tall and was 267 lbs. I also have Cigna. I needed to have three months steady of doctor supervised weight loss/dieting. I did not have to lose any weight, just have it documented with the doctor. You should be OK insurance wise.

As far as the surgery you want, talk to the doctor and explain why you want the DS. If he has a problem with it, you will know that he's the wrong doctor for you.

Regarding the amount of weight you expect to lose, just know that my PCP told me to get a gastric bypass since I needed to lose at least 100 lbs. and her experience was that I'd only lose about 40 lbs. with the band. I went with the band because that's what I was comfortable with and I lost 150 lbs. I weigh less than my PCP now so don't assume the weight loss based on the surgery.

Good luck and keep us posted.

[SuzeMuze 338]

Is it just me or is that a bit confusing? I'm thinking this means that the plan does not cover any obesity treatment for those who do not have "clinically severe obesity". A BMI over 40 or between 35-39.9 with comorbidities is defined as clinically severe obesity. So I definitely meet this requirement with a BMI of about 52. I'm also thinking that the last part about treatments that are peer reviewed and scientifically shown to be safe and effective means that the 5 procedures covered in the Cigna bariatric surgery coverage policy are all covered (gastric Bypass, gastric banding, RNY, vertical banded gastroplasty and BPD/DS for those with BMI over 50).

I don't have Cigna, but for what it's worth, what "peer reviewed" meant in my case (because I was initially denied over a screw up concerning who was documenting what as far as my diet went) was that the case needed to go beyond a simple stamp of approval and be reviewed by actual doctors to determine whether my case was actually appropriate to move forward. "Peer review" in my case was just another way of saying someone is actually going to look at my paperwork and decide whether the treatment was going to be fair and effective.

[CowgirlJane 14,259]

The part of this thread that confuses me is surgeons telling high BMI people they will only lose 60#....

I started at 51 BMI and have been maintaining at 24-25 BMI post sleeve.

I am 5"5" and lost 160# with sleeve.

I was a revision from band to sleeve. First surgeon I consulted said I should do gastric bypass and didn't even educate me on sleeve option.

It seems to me consulting with a surgeon who advocates DS might be a good idea since you really want this.

[samuelsmom 670]

@@CowgirlJane

I can answer this! 60% is the average excess weight loss according to the statistics, however, it is just that, an average. For example, an average flat screen tv might be around $500, however, we all know that you can buy a TV for anywhere from $150 up to $3500 (or more). No one should use this average as a predictor for themselves. We all know there are people who don't succeed and lose nothing and those that lose 120%. All of that is included in the average. It is just another piece of information. I personally would never base a weight loss surgery decision on this.

[Brianna_Nicole 4]

Wow, thank you all so much for your replies! Its really helpful. I have to go back and respond to everybody now

[Brianna_Nicole 4]

Your reasons are why I chose the DS as my surgery.

It's your body. Tell him you want the DS. I would also go over your reasons with him. Show him you have done your research.

I also have Cigna. And they approved me no problem. But I would call them and discuss it. And make sure you note the times and who you spoke with.

Thanks for the advice! I think you're right, it would be best to make an appointment and discuss it with him and show him my research. Ultimately I think I should present him with my concerns and see what he thinks. I highly respect him as an expert so if he strongly advises against the DS I would listen. I have heard so many different experiences with Cigna! Either they say it was a breeze or it was horrible.

How has your experience been so far with the DS? Are you glad you chose it?

[Brianna_Nicole 4]

ill only say this, the difference between the VSG and the DS is negligible. The routines you have to adhere to are almost the same as well. But I am curious why you think you can only lose 60 pounds on a VSG? the weight loss doesnt stop at a certain point. there are many sleevers who weighed more than you and lost a lot more than what you want to lose. Heck there are those who weighed less and lost more. The key is with either surgery YOU have to make the lifestyle change the surgery only helps you make those changes , sure at first its because you have to, but you are supposed to learn as you lose to change your eating habits and lifestyle, and go to the gym and eat healthy.

Personally i chose the sleeve due to the lower complications, easier surgery and recovery, and the much lower risk of dumping syndrome and malabsorption problems. But whatever helps you is great I am slated to lose over 170 pounds from the sleeve.

Either way you choose, you may want to do more research on the after routines and what YOU have to do for yourself after either surgery before you commit.

Good luck wih your decision and with your weight loss.

Either way, you can do it!

Thanks for the reply When I said I could expect a loss of about 60 pounds, I was referencing the average weight loss statistics I've been reading about. I realize that my experience can be much better or much worse than this, but the average is the best predictor I have to go on. I also have to consider that I have a long history of losing a good amount of weight and gaining it all back. This is a big reason I'm inclined to pick a malabsorptive procedure that has better statistics about regain. I just want to make the best choice for me.