BC/BS Policy: Something Interesting

[Guest guest]

In a message dated 7/24/01 5:40:59 PM Central Daylight Time,

chull1@... writes:

<< The author

of this policy seems positively disposed to BPD with DS (but NOT BPD

alone). It seems like this should be leverage for all of you BC/BS

types, and I will even use the paragraph below if I need to apeal

with Aetna: >>

In the case of BCBS of Ala, they only give creedence to the NIH reports,

which have not been updated since 1991. I understand they will be updated in

the Fall of this year, but don't know if that means they will start to cover

the DS.

Cindy W in MS

[Guest guest]

Hi Everyone,

I found the BC/BS policy at:

http://www.regence.com/trgmedpol/surgery/sur58.html

The policy speeks negatively about the original Scopinaro procedure,

and that is specifically excluded. However BPD/DS is NOT

speicifically excluded:

" The following surgical procedures are considered investigational:

Adjustable gastric banding

Biliopancreatic bypass

Distal gastric bypass "

Also the text is quite positive to BPD/DS and quotes Hess, Marceau,

and Baltasar. The quote from Baltasar reflects his older paper, and

in his new one in 2001 he reports acceptable morbidity. The author

of this policy seems positively disposed to BPD with DS (but NOT BPD

alone). It seems like this should be leverage for all of you BC/BS

types, and I will even use the paragraph below if I need to apeal

with Aetna:

Biliopancreatic Bypass with Duodenal Switch

The largest case series of the above procedure is reported by

Marceau, who reported on 465 patients who underwent the duodenal

switch procedure compared to 252 patients who underwent the

biliopancreatic bypass. (24) It should be noted that in addition to

the preservation of the duodenum, the common segment was elongated to

100 cm. The authors noted similar weight loss in the 2 groups. In the

duodenal switch group, a lower incidence of metabolic abnormalities

such as protein malnutrition was noted, which prompted reversal of

the procedure in 1.7% of those undergoing biliopancreatic bypass vs.

only 0.1% after the duodenal switch procedure. Hess reported on a

case series of 440 patients with variable lengths of the common

channel. (25) The percentage excess weight loss varied between 60%

and 90% depending on the length of the common segment and alimentary

limb. There were 2 late deaths, 1 due to septic shock secondary to an

infected panniculus and 1 related to liver failure. A total of 10

patients underwent revision to lengthen the common segment secondary

to low protein or excessive diarrhea. Seven patients underwent

shortening of the common segment due to inadequate weight loss.

Baltasar and colleagues reported on a case series of 60 patients

undergoing the duodenal switch procedure with a common segment length

of 75 cm. (26) One patient succumbed to liver failure and another due

to malnutrition.

As experience with the duodenal switch procedure evolves,

particularly in patients receiving a 100 cm or greater common

segment, it appears that health outcomes are similar to those related

to the gastric bypass in terms of weight loss and durability of

results. In all cases mentioned above, the authors were satisfied

with morbidity rates. While Baltasar found the morbidity rate

unacceptable, it should be noted that his study subjects all had a

common segment length of 75cm. Morbidity rates were significantly

lower in the other studies in which a longer common segment of at

least 100cm was used. In addition to weight loss, patients undergoing

the duodenal switch also benefit from improvement or cure of their

comorbid conditions such as type II diabetes, hypertension and

hypercholesterolemia. Finally, revision rates with the duodenal

switch are similar to revision rates for the gastric bypass

procedure, both of which are superior to revisions rates for vertical

banded gastroplasty. "