Is Weight Loss Surgery For You?

If you are here you are likely either thinking about WLS or you have already had WLS. Either way, you are in the right place.

I think most obese folks consider WLS and due to the unknown we tend to fear it. Everyone knows someone *or* knows someone that knows someone that had serious complications including possible death from WLS. WLS isn't as scary as it sounds, to be honest obesity carries more risk than the surgery itself. We tend to get used to the risks associated with obesity but surgery? Not so much. We don't worry as much about high blood pressure, diabetes, sleep apnea, joint damage, heart disease, dialysis, and all the other complications that go with obesity but the fear of surgery scares many away. This is not acceptable, surgery is safer than obesity!

You have probably tried to lose weight before, right? Are you still trying? Please tell me in detail how well you are doing with this task? Some can lose weight but they cannot keep it off. Others are unable to lose weight to begin with. This is NOT your fault! Obesity is a disease, it is not a character flaw. Recent studies coming out of Canada are showing that doctors who suggest traditional diet and exercise for weight loss in the obese are seriously under-educated about this disease and if they understood what they believe they know, they would realize the chances for our losing weight on our own are close to zero percent. Old studies show those who are obese and diet and exercise their way to a healthy BMI make a whopping total of 4% of us. New studies indicate that is 0%. I will post this study elsewhere.

Jenny Craig, Weight Watchers, meals delivered to your home... do you know what all these have in common? They all survive on repeat business. Stop and think about how many people you know (including yourself) that have tried these? Many lose quite well. Kirstie Alley comes to mind. She did very well but as soon as she stopped the program she regained her excess weight and maybe added a few pounds on top of that. These programs survive on repeat business, people lose well, stop the program, regain, and return to do it again. Is this really productive?

WLS isn't a sin, obesity isn't a sin. It isn't a character flaw either. It is a disease. It's time we all start treating it as such. Being obese is not a horror, staying obese is a horror and especially if you have options. Where there is a will there is a way.

Typical feelings we have about ourselves is a lack of discipline, a lack of self control. A lack of self esteem is common. I will cop to them all! I just didn't have what it took to do it on my own. But then had I been diabetic I couldn't have treated that on my own without medical intervention either! We often times start hating ourselves, our lack of ability to lose weight, we don't like the way people look at us, we don't leave our homes, self loathing. It's all a part of what we go through.

Surgery does not cure everything but it sure gives all of us an opportunity to start a new life with improved self esteem.

Take a chance, get your life back!

You Want Surgery, So Now What?

So now that you have chosen a surgery type, now what?

Now you need to research to see if your insurance covers WLS. Most people who have medical insurance do not have WLS benefits. If you have WLS benefits, count your lucky stars!

WLS benefits are covered under group policies only. Private policies do not cover WLS and the reason is that all the people (majority) who do not have WLS benefits would be buying private policies in order to have insurance companies pay for their surgery. As soon as their surgery was complete they would drop the policy. No insurance company could afford that for long. Thus, private policies do not cover WLS.

Group policies do cover WLS IF the WLS premium is paid. Let's say you work for a large company, your chances for having WLS benefits are good. Typically the larger companies will pay the additional premium for WLS. If you work for a smaller company it is unlikely you have the right benefits. Smaller companies cannot typically afford the expensive premiums. They cannot just cover one or two employees, it is all or none. Either they have to cover all employees or no employees.

Call your insurance company, ask if you have WLS benefits. Regardless if they say you do or you do not verify this with your own eyes. When you call your insurance company you are talking to a first level employee. They are not typically experts in insurance. Whether or not they claim you have benefits ask them to email you a link to your on line policy showing where WLS is included or excluded. Do not take their word for it.

If you do have WLS benefits ask them what you need to do to qualify for surgery. Most companies require part or all of the following:

A BMI of 35 or greater and very specific comorbidities such as high blood pressure where you need medications to control your disease. Borderline hypertension that is controlled by diet and exercise does not count. And/or, diabetes and no, prediabetes does not count. You must be a full blown diabetic on medications to control your blood sugar. Things like a family history of obesity, high blood pressure, diabetes, these do NOT count. Your insurance company does not care if your mother is diabetic or not, they want to know if YOU are a full blown diabetic.

Issues such as joint damage, back pain, headaches, PCOS, asthma, ... none of these issues matter. Well, they do to you but they do not matter to your insurance company in the least when it comes to qualifying for WLS.

If you do not have medical comorbidities such as the above you must have a BMI of 40 or greater.

Some insurance companies require you to prove through various types of medical records that you have had a BMI of 40 or greater for the last five years.

Some insurance companies require you to do a 3-6 month medically supervised diet. This means (usually) that you have to go to your nutritionist or physician every month for 3-6 months to be weighed and measured. Then your health care professional must document that they weighed and measured you and discussed with you diet and exercise. If you miss as much as one appointment your insurance company has the right to make you start over the entire medically supervised diet.

Many insurance companies require that you go to a nutritionist for an evaluation of your diet.

Many insurance companies require that you go to a bariatric surgeon to evaluate your weight.

Many insurance companies require that you go to a psychologist for a psych evaluation.

Many insurance companies require that have a sleep study done to see if you have sleep apnea.

Let's be honest here, they do not make this an easy process.

What if you do not have WLS benefits on your insurance? Well, welcome to the world of self pay. I'm not being snitty, I've self paid twice so I fully understand. Once for a Lap Band and again for a revision from band to sleeve. If you are in this position I can empathize with you. Please note, there are no organizations that will give you money for WLS. No doctors will do your surgery for free. They are asked on a daily basis and they would go out of business if they did free surgery, the costs associated with WLS are great in number. The cost of a Lap Band is $4,000 and that is just for the band. That does not include OR time, the anesthesiologist, medications, anesthesia, nursing, or all the other costs associated with surgery.

One of the many issues I have learned over the last four years is that if someone wants surgery badly enough, they will find a way to get it. Some save for years, some take from their childrens college funds. Some refinance their homes, some sell off personal items, some get 2nd and 3rd jobs to pay for surgery. People that want it bad enough find a way. It's a cold and harsh reality, yet true.

The next step is to find a doctor. Now, I realize this sounds odd. Most would have their surgeon help them pick a surgery type. That's fine as long as you go to a surgeon that does all the major procedure types. For example, let's say you want Gastric Bypass and you go to a surgeon that is a band mill, meaning they only do Adjustable Gastric Bands. They sell a product, their product is a Gastric Band. If you go there asking about a procedure they do not know how to do they are going to tell you the evils of all surgery types they do not do. Let's face reality here, doctors are in business to make money just like the rest of us. We all go to work to earn a living. Asking a band mill surgeon about Gastric Bypass is like asking a Toyota dealer to tell you all the best aspects of buying a Honda. They are going to push what they sell. Thing is... *you* are the person that has to live with your surgery type for the rest of your life. It is you that has to decide just what you can live with and what you cannot live with.

So either decide on a surgery type and then choose a surgeon that does that surgery or go to a surgeon that has no vested interest in which surgery you choose, you will get a much more balanced answer and more balanced suggestions to consider.

Please see "Researching Mexican Lap Band Doctors" on how to research your doctor, it will work for both US and MX surgeons. Please see "Researching Mexican Sleeve Surgeons" on how to research your doctor, it will work for both US surgeons and MX surgeons for sleeves and bypass. For DS the doctors are extremely limited and you should check on the www.DSFacts.com website for suggested surgeons.

If you have WLS benefits on your insurance get a list of all the doctors they contract with and start going to seminars. Remember, go to a surgeon that does the surgery type YOU want. YOU have to live with this surgery type for the rest of your life, don't let a surgeon talk you into the surgery type he performs instead of the surgery type you want. I promise you, you will regret it if you don't.

If you do not have WLS benefits on your insurance plan, or if you do not have insurance at all then you can go to any doctor you wish. Remember, medical tourism is a growing industry. Surgery is MUCH cheaper and equally as good (with the right research) outside of the US. I did it, lots of people do it. I went to Mexico for my band as well as for my sleeve.

Go to lots of seminars, meet the doctors (if in the US), get a feel for them. See which doctor you feel comfortable with. In some ways the most important issue is surgical skill but you know, unless you get a sleeve you'll need follow up care for the rest of your life. You really need to go to someone you like and trust as well. If you hate your surgeon you are less likely to go for follow up care and that will affect your weight loss.

There is such a thing as a Center Of Excellence or a COE. You will see this often on various WLS message boards. Please do not assume this makes the surgeon good. Some of the worst surgeons are a COE, it merely means the hospital they work out of meets certain requirements. It means absolutely NOTHING about surgical skill.

Choose a surgeon with lots of experience. There is a learning curve to every surgical procedure including removing toenails! Don't be the guinea pig, be the patient that goes to a good, experienced surgeon with great stats, lots of skills, and oozes compassion and understanding of obesity.

Now it is time to choose a surgery type and get your life back!

Which Surgery Type Is Right For You?

There are several surgery types but there are four that are the most popular. I'll start with the top four from least invasive to most invasive. Keep in mind, the less invasive the surgery the less weight you will lose, statistically. The more risk you have for surgery the more you are likely to lose.


*****If you take nothing else away from this section of my blog please understand one thing, there is NO surgery type that fixes white carbs. No surgery type will prevent you from absorbing sugar, flour, rice, or pasta. That one is on us to change, not the surgery. Surgery is just a tool for us to lose our own weight. We can have surgery to limit the quantity of food we eat, we can have surgery to prevent us from absorbing all the calories that we consume but no surgery type prevents us from absorbing every white carb we consume.*****


ADJUSTABLE LAP BAND

Inamed, Inc originally came up with the Adjustable band and later sold the rights to the Lap Band System to Allergan who currently owns it. This band was approved by the FDA for use in the US in 2001.

The band is a restrictive only procedure meaning that it will limit the quantity of food you can consume at one time but you will not malabsorb nutrition or calories.

The Lap Band System was originally approved in Mexico in 1991. The Mexican doctors are the surgeons that perfected the surgical technique used today. Mexican surgeons were also the primary proctor surgeons (Proctors train other surgeons in a given procedure or technique.) that trained US surgeons in 2001. They still proctor many surgeons in the US and other countries. An interesting side note is that when Inamed owned the Lap Band System they had more strict requirements to be a proctor. You had to have at least 100 bands under your belt and low complication/morbidity stats before you could train another surgeon. Since Allergan took over they only require that a surgeon has performed 10 bands before they can teach another surgeon. The reality is that proctoring has "dumbed down" to "watch one, do one" and this is unfortunate. In order to be Allergan certified you must be proctored by another surgeon. When Inamed owned the rights to the Lap Band they would revoke a certification if the doctor proved to have a higher than normal level of complications. When Allergan took over they changed the policy, returned certifications to all surgeons that previously had high complication and morbidity stats. My personal opinion? They just want to sell bands and lots of them.

Johnson and Johnson decided they wanted a piece of the pie and their band, the REALIZE band was approved by the FDA in 2008. They claim big differences between REALIZE and Allergan Lap Band System but to be honest? They both work about the same way. The significant difference for patients is the port. I don't care for port placement of the REALIZE band but the Allergan is taller and tends to stick out more at goal.

About the band...

The band is a silicone band that goes around the upper part of your stomach creating a pouch. Your stomach takes on the shape of an hourglass. The whole idea is that you eat filling the upper pouch of your stomach and you can get full on a small quantity of food. There is a narrow pass through from your upper to lower stomach, it takes time for food to drain from your upper stomach to your lower stomach. There is a nerve at the top of your stomach called the Vegus nerve. This is the brain of your stomach, it basically tells your brain when you are full. So, you stay full on a small quantity of food for an extended period of time.

Three advantages of this surgery:

1) Least invasive
2) Removable
3) Up front surgery fees are more affordable than other surgery types

Three disadvantages of this surgery:

1) Slowest weight loss, least weight loss, highest regain, most mechanical problems of all main surgery types
2) Maintenance for life, hard to find follow up care if your surgeon moves, retires, etc.
3) Very high complication rate and costly for self pay folks


VERTICAL SLEEVE GASTRECTOMY

The VSG is a restrictive only procedure meaning that it will limit the quantity of food you can consume at one time but you will not malabsorb nutrition or calories.

The VSG (aka Sleeve) is where your surgeon will surgically make your stomach smaller. Your stomach has an elastic portion called the fundus. The fundus of your stomach can hold 18 cups of food. Clearly, this is not a benefit to those trying to lose weight. In the sleeve procedure your surgeon will remove the outer curvature of your stomach leaving a small, banana shaped portion of your stomach.

Studies show that obese people tend to produce three times the amount of Ghrelin as a naturally thin person. Ghrelin is a hormone that is mostly (but not all) produced by the stomach and Ghrelin is what tells your brain that you are hungry. People with the sleeve tend to lose the majority of their hunger. Doctors are not in agreement if Ghrelin will return later in life. Quantities of food vary from surgeon to surgeon but theoretically when your sleeve matures in 4-6 months you should be able to eat about 3oz of solid, dense protein such as steak or about 6oz of soft foods such as cottage cheese.

There is a bit of history with the Sleeve procedure. It used to be part one of a two part procedure. Today it is used as a stand alone procedure. If someone has a very large BMI they are often times too high risk for a full Gastric Bypass or DS surgery. So traditionally surgeons have performed a sleeve procedure and sent the patient home to lose enough weight to make a riskier and longer procedure safer. Later they come back and have the malabsorption added to their surgery type. Today they are making smaller stomachs and not doing the malabsorption for those that merely want restriction alone. The procedure itself is NOT new, what is new are the weight loss statistics since it was previously used as part one of a two part surgery.

There is a chance of a vitamin B12 deficiency. Your stomach produces an enzyme called Intrinsic Factor or IF. IF is needed to absorb Vitamin B12 via the stomach. Some people produce less IF after surgery and they need to take Vitamin B12 under their tongue instead of swallowing a tablet.

Three advantages of this surgery:

1) Safest surgery LONG term of all WLS types
2) Drastic reduction in hunger due to removing the portion of the stomach that over produces Ghrelin
3) No maintenance, no aftercare

Three disadvantages of this surgery:

1) Not reversible
2) Less than 1% additional *surgical* risk over the Adjustable Band
3) Risk of B12 deficiency


ROUX-EN-Y aka - GASTRIC BYPASS aka - RNY

Gastric Bypass is considered the Gold Standard for WLS in the US. Many believe the Adjustable Band and Gastric Bypass will be considered "yesterday's procedures" and the VSG and DS will be tomorrow's procedures due to better weight loss and improved resolution of comorbidities. This topic is under debate by both surgeons and patients. But the fact remains that the Gastric Bypass procedure is probably the most common surgery performed today in the US.

This is the preferred method of performing gastric bypass surgery. In Roux-en-Y, your stomach is stapled to create a small pouch and a passage for food to go around (bypass) a section of your small intestine.

A gastric bypass first divides the stomach into a small upper pouch and a much larger, lower "remnant" pouch and then re-arranges the small intestine to allow both pouches to stay connected to it. Surgeons have developed several different ways to reconnect the intestine, thus leading to several different GBP names. Any GBP leads to a marked reduction in the functional volume of the stomach, accompanied by an altered physiological and psychological response to food. The long-term mortality rate of gastric bypass patients has been shown to be reduced by up to 40%; however, complications are common and surgery-related death occurs within one month in 2% of patients depending on the target group being studies. Bottom line is the larger the patient and the more illnesses (comorbidities such as high blood pressure, diabetes, etc.) the higher the risk due to the invasive nature and length of the surgery.

This surgery type is ideal especially for Type II diabetics and those with uncontrolled reflux (GERD) not caused by a hiatal hernia or obesity.

The problem with this surgery type is that the stoma (pass through from pouch to small intestine) can dilate in as much as 1 in 5 patients. This causes a complete lack of restriction 2+ years post op. The stoma is designed to keep food in the pouch to provide satiety for several hours after eating. If the stoma dilates, or stretches, there is nothing holding food in the pouch and the patient tends to feel hunger all the time. Since Bypass folks only malabsorb calories for 6-24 months, if their stoma dilates they are hungry all the time and 3 years post op they are no longer malabsorbing calories... the regain starts.

Many believe that Gastric Bypass is not reversible. Theoretically it is totally reversible. This does not mean you should go into this thinking if it does not work you can always have it reversed. It is a huge and major surgery to try to reverse and it cannot always be done. Many believe the surgery is not reversible because intestine is removed. Intestine is not removed in this procedure, it is bypassed thus the name, Gastric Bypass.

For every 120cm of small intestine bypassed people tend to malabsorb about 33% of calories. This is not a permanent feature. We all have something in our intestines called villi. Villi are responsible for absorbing fat, calories, and nutrients. The body has an amazing way of compensating for alterations we choose to make. Within about 2 years the body creates more villi to absorb fat and calories and the patient will never absorb nutrition properly again. Nutrients are absorbed in very specific parts of the intestine, for example iron is absorbed directly under the pyloric valve (the part of the stomach that controls how fast the stomach is emptied to the small intestine, this is bypassed in RNY folks, btw) and this part of the intestine is bypassed so you will need to take supplements for the rest of your life to make up for this. If you cannot or will not take supplemental protein, vitamins, and minerals and if you will not agree to have vitamin labs done at least annually you should NOT have this procedure.

A Welsh study recently announced that 85% of the time within 10 days of surgery patients are in full remission of Type II diabetes. This is significant in the sense that it is changing the way science is approaching diabetes in prevention as well as treatment.

Three advantages of this surgery:

1) Ideal for Type II Diabetics and those with uncontrolled reflux not caused by a hiatal hernia or obesity
2) Fast weight loss the first year especially for insulin resistant people such as PCOS patients
3) Dumping - some consider this to be an advantage, some consider it a disadvantage. For about 1/3 of bypass patients if they consume high sugar or high fat foods they "dump" and for many this keeps them on the straight and narrow, it keeps them from eating foods that are not ideal for weight loss.

Three disadvantages of this surgery:

1) Significant morbidity rate for very high risk patients
2) Ability for the stoma to dilate causing increasing hunger and weight regain
3) Side effects such as reactive hypoglycemia, possible seizure disorder, vitamin deficiencies, and necessity for labs annually for a lifetime. When this surgery works well it works very well. When complications happen they can be quite serious.


DUODENAL SWITCH aka DS

In this procedure, the surgeon removes about 80 percent of the stomach, forming a thin sleeve-like stomach. The valve that releases food to the small intestine remains (duodenal switch) along with a limited portion of the small intestine that normally connects to the stomach (duodenum). The surgery bypasses the majority of the intestine by connecting the end portion of the intestine to the duodenum near the stomach (biliopancreatic diversion). This weight-loss surgery is effective but has more risks, such as malnutrition and vitamin deficiencies, and requires close monitoring.

This is a procedure that is nice in the sense that the first half of the surgery is a Vertical Sleeve Gastrectomy and the second half is the DS, or bypassing of intestine. There is no concern for dilating a stoma as in Gastric Bypass and the long term weight loss is the best of all surgical procedures. But as explained earlier, the thing about WLS is that the less the risk, the less the weight loss. The greater the risk in surgery the greater the weight loss. This is the greatest risk of all surgery types for malnutrition and various vitamin deficiencies yet it provides the best long term weight loss stats. It does not have "more" complications than Gastric Bypass but if complications occur, the complications are greater in nature.

By the time you have this procedure you will not absorb 80% of fat, 50% of protein, and a handful of complex carbs. A high fat diet is not only permissible with this surgery type, it is necessary.

One down side to this surgery types more-so than other surgery types is that if you consume a great deal of white carbs such as flour, sugar, rice, or pasta you will have gas that is not pleasant to the nose. This happens with RNY as well but not to the same degree.

Not all surgeons can do this surgery type. It requires a skill as well as an art, much experience is necessary to perform this particular surgery safely and effectively. For detailed information please see the following website:

www.DSFacts.com

They can do this surgery type far more justice than I can.

Three advantages of this surgery:

1) Best weight loss and best long term weight loss stats of all surgery types
2) Not only the ability but the necessity for the patient to consume a very high fat, high protein, low carb diet
3) A more normal stomach than bypass, there is no pouch and no stoma

Three disadvantages of this surgery:

1) Highest risk surgery type
2) Highest risk for vitamin and mineral deficiencies
3) Not appropriate for vegetarians or vegans or those unable to comply with a high fat diet


There is another procedure type, it is one I cannot suggest to anyone for any reason:

MINI GASTRIC BYPASS aka MGB

This was the original bypass procedure and due to bile leaking into the stomach and esophagus (causing SEVERE burns) ALL the better surgeons stopped doing it in the 1970s. It is merely dangerous and only the bottom-feeder surgeons even do this procedure. It is technically easier to do than RNY or full gastric bypass but due to the danger to the patient none of the skilled doctors with good reputations will do it.

GASTRIC SLEEVE PLICATION aka GASTRIC IMBLICATION, aka Plication

This is a new procedure, as of this writing the best long term stats are only 18 months old. It is similar to a sleeve but instead of stapling and removing tissue it requires sutures instead to create a sleeve shape. No part of the fundus is removed.

It is restrictive only and not malabsorptive.

Three advantages of this surgery:

1) No risk of a staple line leak however, there can still be a leak from perforating the stomach.

2) There is no tissue removed (This creeps out some people who are considering the sleeve.)

3) It is done by lap instead of full open incision surgery.

Three disadvantages:

1) It will be extremely difficult to revise to anything else but DS if it does not work and it is unknown if it will work because there are no long term stats available.

2) Reflux is much more significant for this surgery type vs. the sleeve. Unfortunately, there is little to do to resolve this if meds (PPIs) do not help.

3) The sutures can give way over time and the stomach would be larger thus the person could eat more. Speaking of sutures one of the dangerous aspects of this surgery is the blood supply in the stomach. The stomach has a rich blood supply and many large blood vessels on the left side of the stomach. When the plicated stomach is folded in and sutured it can potentially cut off the blood supply and the stomach tissue will die and become necrotic. This can happen immediately post op or months down the road.

****NOTE NOTE NOTE****

8/17/11

As of this writing the doctor who originally created this surgical procedure was at a Germany Bariatric Conference within the last week and he strongly advises physicians to explain this procedure is a temporary weight loss procedure that is not expected to give long term results. It is sill investigational and his own 3 year stats show significant regain at the 3 year point post op. The creator of this surgical type does not suggest this surgery for long term weight loss.

VERGITO

More info and animation coming soon. If you want to see an animation of the procedure please visit Dr. Husted's website, he is the only surgeon in the US that does this procedure: http://johnhustedmd.com/


Now it is your job to determine which surgery type is right for you. First you consider if you want restrictive only (Bands/Sleeves) or if you want Restriction AND malabsorption (Bypass/DS). The greater the risk the better the weight loss and long term regain stats. It's a trade off, whatever you think is right for you.

Remember, if a doctor can only afford to advertise on www.youtube.com, it might behoove you to look elsewhere for a more skilled surgeon.

Finding a Surgeon - How?

There is just so much to write here. So much!

If your insurance is paying for your surgery the first thing is to determine your surgery type. The second thing to do is to find out who your insurance company contracts with and get that list. Go to every seminar for every doctor. Avoid the band mill type places, find a doctor that does all the major surgery types. If you want Gastric Bypass and you go to a surgeon that only does lap bands do you really think that doctor is going to try and sell you bypass? Of course not.

Doctors put on seminars for one reason and one reason only. To sell themselves to patients. They are not doing these seminars for your benefit, it is a method to give the same lecture to a group of people. It's a method of advertising. The doctor is selling his service, in this case Weight Loss Surgery. He is not going to use an expensive mode such as a seminar to talk you into going to one of his competitors.

Doctors are in business to earn a buck, that's okay. That is the profession they chose just like you chose the profession you practice. There is no rule that says a doctor cannot earn his living practicing his trade. But the bottom line is it is still a business and run like a business. The doctor is just like the car dealer, a Toyota dealer is not going to encourage you to buy a car they do not make, they are going to encourage you to buy a Toyota. A Band doctor is not going to talk you into Gastric Bypass if he does not do Gastric Bypass. He is going to emphasize all the good parts of the surgery he does do and brush off the procedures he does not do. You would do the same in his shoes.

This is why you choose a surgery type first and then you choose a surgeon. YOU are the person that has to live with this surgery type for the rest of your life, make it the right surgery type for you, not the surgery type that is in the best interest of your doctor's bank account.

So you have insurance (those without insurance or without WLS benefits on their insurance plan will be discussed further down.) and you need to find a surgeon. You have picked out your surgery type and you have a list of the doctors that contract with your insurance plan. You have ruled out the doctors that do not do your surgery type and you have gone to their seminars.

Do you need to *like* your surgeon or is it more important that his surgical skill is tops? Well, the answer to that is both. There are so many surgeons out there that want a piece of the bariatric money pie that there is little need to go to someone that is really nice but lacks in experience or skill. There is also little need to go to someone that is great in surgery but is a butt in his office. You have a right to both. The reason you want a skilled and experienced surgeon that is someone you like and respect as a human being is because if you have any other surgery type than a sleeve, you will be getting to know your surgeon well. All surgery types except sleeves require a lifetime of aftercare. Bands need fills and various check ups, Bypass and DS need labs for life. Now, with that said many bypass and DS folks do have their PCP do annual labs but if those labs are not up to par it is typically the bariatric surgeon that changes the vitamin regimen. If you do not like your surgeon you are not likely to go for follow up appointments and you are not likely to be honest about concerns and medical problems, weight loss or weight gain. So it really is important to find a surgeon you can be honest with, share personal thoughts and feelings, and overall just someone you feel comfortable with.

NO BARIATRIC COVERAGE ON YOUR INSURANCE PLAN OR NO INSURANCE AT ALL

Welcome to my world, the world of self pay.

Most people do not have WLS coverage even if they do have insurance. Most have insurance through an employer and it is the employer that needs to pay an additional premium on top of major medical for WLS benefits. With the economy today people are lucky to have basic insurance. Employers are saving money anywhere they can and sadly, that includes WLS premiums. It is not the insurance company that isn't offering it for group plans, it is the employer who can't pay the expensive premiums.

Private policies typically do not cover WLS for reasons explained earlier. So the bottom line is that we have a lot of people that have no insurance or they have insurance and no WLS benefits. They are self pay. If they do not have access to Medicaid or Medicare, and their insurance does not pay they are left with self pay. The downside to that is they are self pay, the upside to this is that they can virtually go to any surgeon they want and - in any country. I'll discuss that later in a section for Medical Tourism. But for now we are looking at US surgeons.

So you now have decided on a surgery type, you have obtained a list of all the bariatric surgeons on your insurance plan, you have ruled out all those who do not do your surgery type, and you have been to their seminars. You have ruled out those that give you the heebie jeebies, those that are so arrogant that you can't stand being in the same room as they are, doctors that do not answer questions in a way that makes you feel like you are walking away with more knowledge than you walked in there with, and you have narrowed your list further. Now what?

Now you start your research.

Sit down and make a list of things you require of your doctor and a list of things that you prefer in a doctor. For example, it might be something like this:

I require from my doctor:

1) FACS affiliation
2) ASMBS affiliation
3) A minimum of 500 (name your surgery type) procedures
4) A hospital instead of an outpatient surgical center
5) An office staff I can deal with and tolerate
6) (List your requirements)

I PREFER my doctor have:

1) A location reasonably close to my home (depending on surgery type this may or may not be possible.)
2) A nutritionist on staff vs. at a different location
3) A psychologist on staff vs. at a different location
4) ALL aftercare included in the cost of surgery (Get this in writing)
5) Support groups held weekly/monthly
6) (List your preferences)

This allows you to narrow the list down further.

Myth Or Fact?

All doctors are ethical and would never lie about affiliations? What do you think?

It is a MYTH. Many doctors will claim affiliations they do not really have. In order to be FACS one must meet very specific requirements. Many doctors will claim this affiliation but it's not true, they keep the affiliation until www.FACS.org catches them and requires they remove these letters from the end of their name. ASMBS is the same.

Doctors also claim that they have performed many more surgeries than they really have. This one is very hard to verify one way or another. I know of one Las Vegas surgeon that claims hundreds and hundreds of sleeves but as of today's date he has done a grand total of "3" sleeves. Yes, three. Yet when you call his office the staff will claim hundreds and hundreds of sleeves AND this doctor is a Center of Excellence. Scary, right? It is scary.

MYTH OR FACT?

You cannot verify all doctors for FACS or ASMBS affiliation.

MYTH. You most certainly can verify this information.

www.FACS.org

And:

www.ASMBS.org

Just go to the websites and do a search of your doctor, verify what you are being told is truth.

Please remember, the doctor will have a coordinator. It is his/her job to sell you surgery after the seminar. Sometimes they will tell you anything you want to hear just to sell you surgery. Yes, they will lie.

The bottom line here really is to know how to verify what you are told and NOT to believe everything you are told just because it comes from the MD office.

You should also get about 10 references for these doctors. Notice, I did not say you should get references FROM these doctors, I wrote to get them FOR these doctors. If you ask the office staff for 10 references you know full well they are going to give you patients that are thrilled to death and never had a problem. You need to find your own references. Go on various boards, find people that tend to be a bit quiet and shy. You see, there are a LOT of patient coordinators posing as patients on various message boards trying to recruit patients to their offices. There are not many doctors that use this method, but they are pretty easy to find. They invite each person to go to their doctor, only their doctor is the best, they cannot suggest anyone else in the whole wide world other than their doctor. Stay away from those folks. Find people that suggest several doctors, people that the majority of their posts are NOT about their doctor. Contact them and ask if you can talk to them on the phone.

There is a reason I suggest you talk to them on the phone. I recall when I was researching for my own surgery, one of the doctor's offices that I called I requested 10 references. They gave them to me and I contacted each one by email. All had wonderful things to say about the doctor. Real or fake? Fake. Upon looking at the IP address for all 10 references it was the same. It was the same person with 10 email addresses.

I'm telling you, the world of bariatrics is a cut throat business and you really can't be too careful. This IS your health, your life, and your future, take the time to do the legwork. Be paranoid, assume everything you are being told is a lie. Verify everything for yourself and take nobody at their word. These are businesses trying to survive in a bad economy, it's not just used car salesmen that are less than honest, it's many people and many businesses.

Does this mean every doctor will lie to you? Of course not, most will not lie. But the key here is that YOU do not know which are telling the truth and which are lying.

What about a death stat? What if a doctor has had a death? Does that mean he is a butcher that you should stay away from? Of course not. Not all deaths are the fault of the surgeon. Some people are *really* high risk and without surgery they will die. With surgery they are extremely high risk. What does a surgeon do? Refuse them a chance? Or take the chance?

Not all complications are the fault of the surgeon. A surgeon can give all the right pre op drugs to prevent blood clots but there is no promise that the body won't throw one anyway. Is that the fault of the surgeon or is that something that is sad but it happens?

What about leak stats? If a surgeon has had a leak does that make him a horrible surgeon? Not necessarily. Some leaks are the fault of the surgeon, some are the fault of the patient, and some are not the fault of anyone, they just happen. So what you are looking for are trends. Does this doctor have a ton of leaks? Higher than the average of less than 1%? There is a learning curve to every surgery type. Your doctor has to go through the learning curve just like everyone else. Make sure you are not his learning curve.

I will post an article on Researching Mexican LAP BAND surgeons as well as one on Researching Mexican SLEEVE surgeons. These articles will help you regardless if you are staying in the US and having surgery under insurance, self pay, OR if you are leaving the country for surgery.

Insurance Hoops - Surviving the Insanity!

Congratulations! You are ready to have surgery. You have decided on a surgery type, you have picked your surgeon, now comes the insurance hoops to jump though for those going through insurance.

Some insurance companies offer limited surgery types. Some will only pay for bands and bypass. Some will only pay for sleeves or DS if your BMI is over 50. What if you want a sleeve and your insurance will only pay for bands and bypass?

APPEAL APPEAL APPEAL!

It isn't a sure bet that your insurance will approve an appeal but what do you have to lose?

Now, every insurance company I have looked into and researched require a BMI of 40 or greater to be approved for weight loss surgery. Most will accept your 35 BMI *if* you have very specific comorbidities. Typically they want to see active high blood pressure, diabetes, sleep apnea, and/or a history of heart disease. Although we have a poor quality of life with back pain, joint damage, an inability to breathe well, borderline high blood pressure, pre diabetes, asthma... those just don't count. They are typically very specific which cormorbidities they require for a BMI of 35 - 39.9.

What if you have high blood pressure but it is controlled with diet alone? No, it does not usually count.

What if you are pre-diabetic? No, it does not usually count.

What if you have a family history of strokes, diabetes, high blood pressure, and/or sleep apnea? No, that does not count.

You have to be actively treated for these things by a doctor with medications and such before the insurance company will consider them comorbidities. Remember, insurance companies are not strong in common sense. You have to think like them to understand them. Yes, they would prefer to pay for your heart attacks, dialysis, and other related expenses than to pay for your weight loss surgery if it is something they do not cover. They act like a computer, computers do not think, they just spit out information. Computers follow rules, they have no common sense. They don't look at the best value for a dollar spent. Information in, information out. That is exactly what an insurance company does. Some people write long letters to the insurance company begging and pleading for coverage when they do not qualify for some reason. It does not matter. The insurance company (think computer) does not care about you as a human being that is sick and miserable. They care if your blood pressure is high enough and if you are obese enough. If the numbers add up they will pay for your surgery. I know it is not right and it is not ethical, but this is how it works so you will do better for yourself to accept this is how it works and approach it from the right angle. No, life is not fair and no, it is not right but they call the shots and they usually get to have their own way.

What if you want DS but your insurance pays for bypass or bands? Many think if they need NSAIDs (Aspirin, Naprosyn, Motrin, etc.) they can appeal based on this since you cannot take NSAIDs with bypass. They will likely deny you because they do offer bands and you can take NSAIDs with bands. (History: It used to be that doctors thought NSAIDs could not be taken by band patients due to causing erosion, that has since been shown to be inaccurate, NSAIDs do not cause erosion in banded people.)

I recall one person that was just sure he could get a non-covered sleeve on appeal based on the fact that he is deficient in Vitamin D. That is a no-go as well. Most of the US population is low on Vitamin D. Supplements will bring it up and therefore if they cover bands and bypass, they are good to go. Keeping in mind that many times the number of times you may appeal are limited, don't waste your appeals on what you know isn't going to work.

What if you weigh 900# and you have no benefits for WLS? You are out of luck. Yes, once again the insurance companies would rather pay the hundreds of thousands of dollars to treat what weight loss surgery would fix.

Many (most?) insurance companies will not pay for sleeves. They consider the procedure to be investigational. The ASMBS disagrees and they no longer consider the procedure investigational. Let's realize one issue here, the sleeve is not new! The weight loss stats are new, not the surgery itself. With some insurance companies - some of the time - you can appeal and get a sleeve by proving it is not investigational. Once Medicare starts paying for sleeves then you will see more insurance companies beginning to follow suit as well.

What if they require a medically supervised diet for 3-6 months? How does that work?

It really depends on the wording of the insurance company. If they want a "medically supervised" diet they want you going to your doctor and/or nutritionist monthly. They want documentation of effort on your part to try and change eating behaviors, exercise, and sometimes psych care to treat a "medical" problem of obesity. (I know, that doesn't usually make sense either, it's like going to your psych for your diabetes!) They want to make sure that every 25-30 days you have been to your appointments. Not 32 days but 30 days. They want your medical provider to document your weight, the change in weight from the previous month, and written data showing they worked with you on diet and exercise.

If they do not specify "Medically Supervised" then they probably mean something like Weight Watchers, Jenny Craig, some sort of proof that you tried and participated for 6 months. Ask your insurance company and if your policy is not clear make them put it in writing.

What if your insurance company wants proof that you have been a specific BMI or greater for the last five years? If you are anything like most, most of us have dodged doctor's scales for years. It might not be in your medical records what your weight was so be creative! What does your weight say on your drivers license? Okay, if you are like most you are at or near your heaviest today but you still show 150# on your license. But, if you told the truth on your license and it shows your BMI is what is required, that can be put toward proof for that year.

Photographs! Some photos are dated by an outside source (other than your digital camera) such as Walgreen's Photo Dept. If it is obvious from dated photos that you met the BMI requirements, that can often times be used as well.

Emergency Room visits - think back to anytime you might have needed to go to the hospital for sutures or a broken bone. They usually insist on weighing you. Those records can be used to prove BMI requirements.

Be creative and find whatever is necessary to prove your BMI if you do not have proof at your MD office.

What if you lose weight on the supervised diet and fall below the required BMI? You are safe. If you met all the BMI requirements in the beginning of the insurance approval process it is okay if you fall below on the required diet. Can you imagine the lawsuits otherwise? They require you to lose weight to prove your mind is made up and this is what you want then they deny you because you did exactly as you were instructed. Lose weight on your pre op diet, it's safer for you at the time of surgery.

Usually you have to meet other requirements that are equally silly to have insurance pay for your weight loss surgery. They want you to go to a bariatric surgeon for an eval. They may want you to see a psychologist to see if you are mentally prepared for surgery, this is just an eval and not an on-going therapy process. If they suggest you need therapy before surgery ask if you are required to go to them for your therapy before they will approve you. It *might* be a way to force you to continue going back for sessions just to pad their pockets. This does not happen often but it does happen. If you want you can always get a 2nd opinion.

They want you to do a sleep study to see if you have Sleep Apnea and this is something weight loss is likely to fix anyway. They want you to see a nutritionist for an eval prior to surgery. This one annoys me as most nutritionists do not have a huge base of knowledge on weight loss surgery. They will tell people to eat far more calories than possible after surgery. All surgery types limit quantity of food. Just how are you supposed to eat 1800 calories a day with a stomach the size of a ping pong ball? Top that off with their instructions NOT to drink your calories and you see my point. They have more training in people that have specific medical conditions such as wheat allergies, need a gluten free diet, etc. Sometimes they may not understand our issues. If you can go to a nutritionist that is also a WLS patient, all the better.

Many nutritionists will give you a diet for bypass but if you have other surgery types, it doesn't work. For example, DS patients NEED and REQUIRE a very high fat diet but their instructions are likely to stay on a low fat diet. DS folks malabsorb 80% of their fat intake and to keep losing weight they absolutely must eat a high fat diet. I can give you many examples but my advice to you is to ask for a combination of what you should eat. What percentage of your daily food should be carbs, protein, and fat? Listen to your doctor and not your NUT (nutritionist) about caloric requirements. Ask how many grams of protein you should be consuming daily. But again, ask your doctor about caloric requirements.

Dealing with insurance companies is no easy task. Some insurance companies are easier to deal with than others. If all else fails, have your surgeon do a peer to peer review with them. That means your surgeons sets an appointment with the doctor at your insurance company and he explains why you must have "X" surgery type instead of what they say they will pay for.

**NOTE: Regarding peer to peer reviews, this is a LAST option. Do not use this for your 1st or 2nd appeal or you *will* be denied. Insurance companies do not want their doctor tied up doing what the appeals department should be doing. So use it as a last and final option.

If that fails you have one more option. Seek the advice of an attorney. There is one attorney that does nothing but this type of work. It seems somewhat affordable and they appear to have a good track record. I prefer not to advertise specific businesses that I have no personal experience with but you can go to www.obesityhelp.com and post most anywhere asking for this man's name and you will get your answer. I would not suggest contacting your family attorney as he does not likely specialize in this and he doesn't know the ins and outs of insurance companies and weight loss surgery. It may end up being far more expensive going through your own attorney just because he may need to take more steps and charge you for each step until he finds the correct appeal paperwork. But clearly, this is your choice.