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.

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.

That is very true that my experience could be very different from the average; I'm just using the statistics to make an estimate for myself. I'm very worried about regain with the purely restrictive procedure because I've been losing and gaining, up and down, back and forth, for years.

I definitely plan to make the changes I have to make and work for the best results, regardless of the surgery. Thank you for the advice, and congrats on your 71 pounds lost since September, thats amazing!!! :-)

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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!

Thanks! Thats good to know about the dietitian. He started me on a 1200 calorie diet and gave me a bunch of recommendations for Protein shakes and 0 calorie drinks for after surgery (high calorie drinks are a huge problem for me!), so I actually did find him very helpful and knowledgeable. Its purely insurance that was worrying me.

How has your experience been with the sleeve so far? I see that you've lost 55 pounds already? That is incredible! Congrats!!! :-)

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.

I have researched this topic too, because I'm only 25 and definitely plan to have kids with my fiance in a few years. You can have babies after having DS surgery. I believe they say to wait 2 years before getting pregnant with all of the surgeries. I understand that the nutrition deficiencies are a big concern for getting pregnant after DS though.

How soon do you plan to get pregnant? I'm thinking maybe if it is very very soon, you might want to have the baby before surgery?

Good luck to you!

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.

Wow, that is amazing!!! What an inspiration... Thank you, your post was very helpful and encouraging Congratulations on being so successful.

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.

Oh okay, that does make sense. So your case was reviewed by doctors at the insurance company? Or you have to provide documentation of a review by your own doctors? Thanks for the reply

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.

My surgeon didn't say I would only lose 60 pounds, that was me estimating based on the statistics I've seen.

That is amazing that you lost over 160 pounds, wow!! That is a huge inspiration for me. Congrats and thank you!

Yes the dietitian was especially focused on Protein when we talked! Did you find it hard to get in all the protein you needed at first? I'm really curious how your diet and typical day is now, 10 years later?

Oh, yes. The rule of thumb (my surgical team never told me this but many others do) is 30 gr/protein within 30 days; 50 grams at 50 days, etc. That wasn't me. Some people can eat way more earlier. It's very individual. I was not one who could eat a lot. I didn't eat 50 grams till 7-8 months out. I did drink a shake everyday; for 2 years! I just couldn't eat enough. Today, lol. I can eat and eat and eat. Not all at once, mind you. For instance, Breakfast might be 3 scrambled eggs w/butter and cream cheese plus bacon. That would be at least 2 sittings. Every meal is at least 2 sittings for me. For others; it's 3. For other people; it's 1.

I've heard that about the 2 step DS being safer as well. I've also seen a lot of posts and discussions in the forums about doctors recommending the 2 step simply to make more money. I have no idea which is more accurate! I want the one step because I know getting insurance to cover another surgery will be a nightmare... If I do go with the sleeve I'm going to make sure I document EVERYTHING so that if it fails and I need a revision, I have plenty of evidence that I followed the rules.

I've heard the more money aspect as well. It's also a shorter time on their feet. My 1 step DS took 4.5 hours. No appendix or gallbladder removal. No adhesions. Just a standard DS. Most people I know are anywhere from 3.5-5.5 hours for the 1 step DS. However, my friends who have been SMO (in the US and Europe) have traditionally gone the 2 step route and I can see it making sense concerning safety. You don't want to be on the table one minute longer than you have to; say my surgeons.

Great job documenting everything. I'm that way. Incredibly organized. It's a requirement to be a successful DSer.

I could come to NYC. Do you have a recommendation? I don't mind travel if it means the best care.

I'll PM these to you.

Edited January 19, 201511 yr by Postop

@brie8989 Honestly, it's been better than I expected. The weight loss has slowed down and I am ok with that. As long as the numbers keep going down, I am a happy camper! One of my big fears was that I would feel like a freak-- go out with my family and sit there having Water while they had steak! For me, I can now eat anything- just in small quantities. I'm so happy when we go out to eat and I can order a regular meal and have it for lunch and maybe dinner the next day Good luck with whatever procedure you end up having.

So, one surgeon didn't think I would lose well with the sleeve since I had already proven I was "not compliant" since after 10 years with the lapband, I was heavier than ever. He was wrong, but I am glad i had that experience of somebody telling me that because it made me think very hard about my role in failure or success.

I thought about what I needed to make WLS work this time. One of the things I realized is that I can be... prideful, self protective. As a lifelong overweight person who has done every diet under the sun, I tended to find nutritionalists etc as very condescending. I had an experience a few years before ...seriously... she had me play with plastic models of food and make meal plans using those models. I was offended beyond belief and really had an issue with nutritionalists after that experience. Like, hey lady, I may be fat, but I am not actually stupid...sheesh

I feel like it was practically devine intervention that sent me to the RIGHT surgical practice with the RIGHT nutritionalist with the RIGHT follow up, support and education. It was like everyone, from the receptionist to the insurance specialist were just what I needed at the time.

After I got to goal, one of the ladies at the office told me that they all could tell I was motivated beyond belief. I didn't realize it at the time, but I actually started the process that I have since continued of allowing myself to be vulnerable, to ask for help, to accept help - to being open to "being wrong" and needing guidance from others. I unconsciously practiced a new life skill that I have since developed further... and my life and realtionships with others is so much better for it. My grown sons have both told me that I have changed so much - for the better - in looks for sure, but also personality.

Anyway, that is a long long winded way of saying - averages are just that! They include people who are not ready to succeed. They include people that have health, age or other issues that may stop them from getting 100% of their excess weight off. They include those unfortunate ones like me when I was banded who simply did not have the right education and support in place.

I genuinely believe that it is possible with the RNY, DS OR SLEEVE to lose 100% of your excess. Clearly, people have even done that with the lapband - just not me.

There is simply one little secret... keep doing what you need to do. My NUT called it "working that sleeve"... and i took it to heart. You have to keep doing it in maintenance too. That is why I hang around here so much. I still have the obesity disease even though I am slim/normal weight and size. I work hard to keep the disease at bay and not slip into old behaviors that permit the weight to come back on.

Do not be fooled, once you lose the weight, you still have the same underlying issues and the weight will come back in a blink of an eye if you start eating like "normal" people do.

Oh, and DS was always my back up l plan when I decided on the sleeve, but I hope to never have to go there as it seems like 2 WLS should be enough for one person!

My surgeon didn't say I would only lose 60 pounds, that was me estimating based on the statistics I've seen.

That is amazing that you lost over 160 pounds, wow!! That is a huge inspiration for me. Congrats and thank you!

When I initially went to my surgeon, he STRONGLY recommended the Lap Band, like you I had already done a lot of research and knew that wasn't the best choice for me (5'9" and 350'ish) . I too had a problem speaking up and almost walked out agreeing to something that I knew wouldn't work and would be a waste of time and money. Once I explained the pros and cons as they pertained to me and that this is what I wanted to do and it was the DS or nothing, he agreed. I truly believe that it was my determination showing to permanently lose weight and that I had done my research that convinced the doctor because from there on out he was 100% behind my decision.

I also had Cigna and had to do a three month supervised diet. My diet was supervised by my primary care and thankfully so. He already knew my weight loss struggles, what had and hadn't worked for me, and as it turned out had already signed off on and getting other patients approved for the surgery so knew exactly what wording needed to be used. The insurance company doesn't care which doctor supervises it as long as it's supervised. My primary care is actually a physicians assistant and Cigna had no problem at all with it. I had constant struggles with my surgeons office turning in the required paperwork to the insurance company, it had even gotten so bad my primary care called the surgeons office and told him what a lousy office staff he had since me and his other patients weren't being helped the way we should and paperwork wasn't being turned in. I really don't know if things would have ever happened if I didn't have my my primary care working as a liaison on my behalf with the surgeons office.

Also, when I first inquired into the surgery, Cigna assigned a nurse as my "caseworker" and at first was hesitant thinking that it was me against the insurance company and she was part of "them" but once I realized she was a neutral party she had so many great suggestions and was such a big help I would highly recommend taking full advantage of this if Cigna has assigned you one. Between doctor visits, labs, surgeon, hospital, anesthesiologist, etc. my out of pocket ended up being my max out of pocket on my insurance which was $4500. It was more than I was anticipating and made money tight but I look at it as I have spent at least that on doctors visits for weight related issues and fad diet over the past year or two. I still have a copy of the letter that was sent into Cigna if you would like a copy so you can see exactly what wording they are looking for.

Edited January 17, 201511 yr by shellyq

"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."

I can help you with this part.

Payment for the following is specifically excluded from this plan: .... • for medical and surgical services intended primarily for the treatment or control of obesity.

This means that plain old obesity isn't covered.

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

You are covered with a BMI of > 40 or BMI of >35 with coexisting conditions

if the services are demonstrated, through peer-reviewed medical literature and scientifically based guidelines, to be safe and effective for treatment of the condition."

This just means all of the current surgical options you discussed. They have all been demonstrated to be safe and effective, through published studies in medical journals such as the Journal of the American Medical Association. These journals do not publish just any study they receive; they must be reviewed by a panel of peers. So if some quack says he thinks he can help you by wrapping your stomach with pipe cleaners, that surgery would not be covered because it has not been proven effective in medical journals.

Your documents don't mention who will be approving your surgery (and they usually don't). It may be a doctor at the insurance company, it may be a nurse, or it may be a clerk who checks to make sure you have completed all the steps. In some cases, a clerk can approve it, but only a medical professional can deny it. So if the clerk thinks it should be denied, it would be passed along to a medical professional for review.

The only thing I can say there is no weight limit you can loose with the sleeve.

I have lost 333 pounds with the sleeve and it took a while but I can eat anything I want (But Don't)

My doctor did not say to wait 2 years after the sleeve, he only mentioned waiting with the DS. Now I need to ask him to be sure...definitely want to lose the weight before I get pregnant!

I have researched this topic too, because I'm only 25 and definitely plan to have kids with my fiance in a few years. You can have babies after having DS surgery. I believe they say to wait 2 years before getting pregnant with all of the surgeries. I understand that the nutrition deficiencies are a big concern for getting pregnant after DS though.

How soon do you plan to get pregnant? I'm thinking maybe if it is very very soon, you might want to have the baby before surgery?

Good luck to you!

Figured out how to quote after the last post! lol...still learning here!

For Bre- our surgeon tried to talk my husband out of the DS and go with the sleeve also. We had done all the research and had the same statistics and reasons that you do. He probably isn't TRUELLY against the DS, but it is a more time consuming, intensive procedure! He probably wants to make sure you are well informed. Also, compliance to the massive amounts of specialty vitamins MUST be a way of life, and so many people don't follow through! Just tell him that after further thought and research, you have decided to go with the DS. as far as the insurience just make sure your employer has the rider. Otherwise, can't help you there as we ended up paying ours ourselves. I just had my surgery Jan 5, 2015. Good luck, and if I can help, let me know