Insurance Questions from a Lurker

[Guest guest]

Hello Everyone,

First off, let me say what a great group of folks you all are and how informative this list is. I have been lurking for about 4 months since a friend told me about the ds surgery. I had never seriously considered wls because of all the horror stories I had heard and all the restrictions on eating. After reading, researching and listening I have come to the conclusion that ds is the route for me.

I do have a couple of questions tho that I am hoping folks can help me out with.

First of all, from what I have read...the major long lasting effect of ds is smelly gas...and that seems to be controllable in most cases. Is there anything I am missing? What other sort of permanent changes in eating habits or lifestyle have you had to make?

Second, I have type II diabetes and am very insulin resistant. I am on insulin and fight everyday to keep it under control. I have heard that in some cases diabetes is greatly reduced or eliminated all together. Is there anyone here that has any experience with this?

And the biggie...insurance..HELP! I have read about all the problems folks have had with insurance approvals. I currently have Premera Health Plus HMO. I called them and was told that they do not cover WLS under any circumstances and they do not pay for out of network coverage at all, being they are a hmo. I currently have the opportunity to switch insurance companies through my employer. My choices are Aetna and Cigna PPO. I have heard about Aetna-hell so I have pretty much discarded that one. I phoned CIGNA and they said they cover for medical neccessity. Has anyone used CIGNA and been approved? Besides diabetes I have sleep apnea and bad knees, so I think I have the co-morbidities covered.

I live in Seattle so Dr. Welker in Portland would be closest to me. Anyone have any thoughts/experiences with him?

Wow...sorry to be so long-winded! I guess I should post more often so I don't bore everyone...lol. But I was sure you folks would have some answers for me. I promise to be more involved now that I have definitely decided to go forward with this.

Thanks so much in advance.

Blessings to everyone.

Leah

[Guest guest]

Dear Leah:

Welcome to our family, pull up a chair and have a cup of tea and let us be of any help we can be.

My name is Tiger and I am almost 2 years post-op with Dr. Anthone in LA. At the time of my surgery I had CIGNA PPO and was approved without any problem at all so they would be my choice but check it out as it has been 2 years since I had surgery.

I had my consult with Dr. A and submitted to CIGNA and I was approved within 4 months I was in surgery although it may have been 5 months.

Hope we can help just ask away.

I don't have any problem with gas although I am now lactose intolerant and if I don't keep my Dairy Care up I will get really bad cramps and gas but other than that the only changes have been that I now live and eat like any normal person.

My stats are below my name for you to see.

Huggles

Tiger Lake

Female

160 lbs. BMI 21.7

224lbs gone

165 1/2 inches gone

6' -- 53yrs young

Dr. Anthone@USC So. Calif.

Open DS

Surgery 1/13/99 384lbs BMI 51.21

Last Visit 4/20/99 315.5 BMI 42.07

7/19/99 274.8 BMI 36.64

9/03/99 259.3 BMI 34.54

10/04/99 252.4 BMI 34.02

10/25/99 231 BMI 32

12/17/99 217.5 BMI 30.2

01/19/00 211 BMI 28

02/20/00 195 BMI 26

04/08/00 182.9 BMI 25

06/07/00 160 BMI 21.7

Hernia repair on 06/07/00 Dr. Anthone

Tummy Tuck & Breast Reduction Dr. Downey

Total Weight Loss! 224.1lbs GONE!

Total inches lost 165!

http://www.duodenalswitch.com (our groups very own web site)

[Guest guest]

Leah:

First, welcome to non-lurkdom. You ask some very good questions and I'll give them a shot. Understand that I am a pre-op and am passing on only what I've learned and not what I've experienced. But I'll be on the other side in less than a month and my wife in around a month after that.

DS gives the best quality of life of any of the various weight loss surgeries. And it has by far the best record of success. To educate yourself further about that I'd strongly recommend the DS web site at www.duodenalswitch.com.

As to questions. I wouldn't say that smelly gas (and BMs) is the worst problem. First, it often is no problem at all. And as you note it is usually, but not always, correctable. Probably the most serious problem is vitamin and mineral deficiencies. This is a bypass where you can have serious mal-absorption problems. If caught early enough these also are easily correctable but you MUST be diligent about getting tested FOR THE REST OF YOUR LIFE. And then there are the surgical risks which exist with any surgery, and make no mistake, this is major abdominal surgery.

If I haven't scared you off, I'll say that the problems are few for most people. To get a handle on what the problems are go to the DS_postop on e-groups. As a pre-op you (or I) can post there but you can lurk and get a very good idea of what problems people have.

Changes in eating habits. First we can't eat very much. At first it's WAY less. And then over the months and years our much smaller stomach stretches out to where we can eat small-normal sized meals. Can you imagine? I can't but I'm told it's true.

Most people find that they become lactose intolerant. All grocery stores sell Lactaid milk. And there are Lactaid tablets if you want cheese - like on Pizza. And with the shortened common channel we can absorb sugar as well as before. So it's important to keep our sugar intake down. Beyond that there really aren't any lifestyle changes you will need to make. Eat less and cut down on sugar.

The really great news is that all the post-ops say that they have a satiety response - feeling full - like they never had before. That amazes me. Also many find that they no longer crave sweets. Another thing that amazes me.

I have mild type II diabetes. Dr. Welker tells me (and I've read) that after this surgery it will be OVER. I find that hard to believe and the doctors say they don't quite understand it but it happens over and over. Like you I also have bad knees, and sleep apnea. I also have congestive heart failure, high blood pressure and high cholesterol, all controlled by drugs. My drug bill will go WAY down after surgery.

Insurance. Go to www. and click on the DS list. On the left you will see files. Click on that and there is an approved insurance file. I just checked today and I think about 37 of our group has put their insurance company down with comments. There are also pending and refused insurance files. I haven't checked them but you may want to.

You say Dr. Welker would be your closest surgeon. We feel so strongly about him that we will be traveling from Texas (where there are no DS surgeons) to Oregon to have him to our surgery. I'd strongly recommend two things. First, join the Welker list. It is on e-groups, WelkerOSSG. Second, go to one of their support group meetings and meet him. All you have to do is e-mail them and tell them you're coming. Everyone's welcome, pre, post, and just looking. It's a wonderful experience. He is a talented surgeon and wonderfully caring individual.

Hope I haven't bored you.

Regards.

Joe Frost, old gentleman, not old fartPre-op, San , TX60 years old, BMI 48Dr. Welker, Surgery Scheduled 11/29/00http://www.duodenalswitch.com/Patients/Joe/joe.html

[Guest guest]

I'd like to thank everyone who so quickly responded to my questions....Rabecca, Joe, Tiger...hope I didn't miss anyone.

I also contacted Dr. Welker. He was very quick in answering my email. I was impressed. He told me he has had better luck with Aetna ins versus CIGNA. Hmmm...that doesn't really follow what I had been hearing about Aetna. I did phone Aetna and was told they cover for medical necessity. I looked up their website and it says that they do not cover the duodenal switch. Now I am perplexed as what to do.

I only have one day left to make a decision.

Any advice anyone? Thanks, Leah

[Guest guest]

Hi Leah, I hate to be negative but i'm afraid that you are stuck between that

famous roak and hard place. Aetna currently is not approving DS , but is

quite reasonable about RNY. Rumor has it that 2 people have been approved by

Aetna for DS since August - which is key because the decided that the

procedure was " investigational " in August.

Those 2 fortunate folks are having surgery in Nov and Dec and have asked

that we not use their names in apeals until after their surgery.

Cigna does not have a good reputation. They are generally hard to deal

with and don't aprove much of anything at all - this is hearsay - i could be

wrong.

I think that if I were you I would choose Aetna - because they will

approve the RNY and might be persuaded to cover your DS in the future.

I'm sorry - I have Aetna - I'm probably gonna change to United Health Care in

JAn -

W

Pre -op Dr.

Denied on 10/26 and fighting mad!!! - Prudential POS

5'5'' 301 - BMI 51

Mire fuera de Prudencial, está muy enojado....