1-818-812-7222

1-818-812-7222 Office Hours: Monday and Wednesay 8:00 AM to 5:00 PM

Blog

Home » Blog

Weight loss Surgery Coverage Changes

January 20, 2015 10:30 pm

Weight loss surgical procedures have been proven to be the only viable option for sustained weight loss when compared to all other modalities, including diet, exercise, behaviors modifications, appetite suppressant, and other less scientific approaches. Different weight loss procedures have had varying degree of success as measured with resolution of the co-morbidities and long term weight loss.

In December of 2014, Blue Cross of California notified the providers of a number of changes in their coverage will be taking place.

One such specific modification in policy involves primary and revision weight loss surgery.

These policy changes have significant practical implications for those seeking surgical treatment for morbid obesity and associated co-morbidities.

First of all, they create a road block for those patients who are not able to provide documentation for the “…6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance.” It also places the responsibility on the surgeon by requiring that compliance with these requiremens are “…. fully appraised and documented by the physician requesting authorization for surgery.”

The practical implication of this is much longer wait between the first office visit with a surgeon and the ability to obtain authorization unless a patient comes in with 6 months’ worth of documentation. The impropriety of such medically unsubstantiated requirements, including the unacceptable and harmful effect of delay or denial on access to medically necessary treatment, was addressed by the ASMBS in the March 2011 position statement on Preoperative Supervised Weight Loss Requirements (https://asmbs.org/resources/preoperative-supervised-weight-loss-requirements). These new requirements are inconsistent with the ASMBS Position Statement and should be vigorously opposed.

The second and in my opinion more restrictive and significant change is for revision procedures. It indicates that any patients in need of a medically necessary revision surgery, must meet the criteria for initial weight loss surgery. This can dramatically limit access to revision surgery for those who are having complications, e.g., of the Adjustable Gastric banding procedures (because they are unable to eat, having constant nausea and vomiting, abdominal pain etc.) or gastric bypass (dumping syndrome, solid intolerance, etc.) but who do not meet the weight criteria or have documentation for 6 months of “ … participation in a non -surgical weight loss …” since they were not trying to lose weight.

This should also concern those who have or perform the duodenal switch as a staged procedure, where the sleeve is done as the first step, to be followed by the completion of duodenal switch operation at a later time. Although I am generally against a staged approach to the duodenal switch operation, this policy change introduces unnecessary and even insurmountable hurdles for those patients for whom this approach is deemed medically necessary.

For all those who are not in California, please note that a lot of policies do start here and propagate to the rest of the country. I would propose that everyone take time to contact their state health insurance providers regulatory agency and voice their opposition to the proposed changes.

The state regulatory agencies are located here. (https://www.dsfacts.com/image-files-new/agencies-by-state.pdf)

Hiatal Hernia Repair- Reflux and Adjustable Gastric Band Revision

January 14, 2015 3:47 pm

Hiatal Hernia is an anatomical weakening or enlargement of the opening in the diaphragm where the esophagus meets the stomach. The defect can allow a section of stomach to slide or roll into the chest cavity. This causes the reflux of stomach content back to the esophagus. Esophageal Reflux may also be occur without the presences of a Hiatal hernia. It is reported that approximately 60% of people over 50 have a Hiatal hernia with about 9% being symptomatic.

However, over the years we have also noticed a significant increase in reflux disease in patients who have had adjustable gastric band placed. Quite frequently the reflux symptoms after the band is ” blamed” on the patient’s eating habit. Most of the time all studies are reported as “normal” and the complaints are discounted. Other symptoms of Hiatal hernia may or may not include shortness of breath, heart palpitations, or a feeling of food being stuck.

It is important to confirm the presence or absence of a hiatal hernia when considering revision from an adjustable gastric band procedure. Any hiatal hernia identified either before surgery or at the time of the operation will need to be repaired surgically.

With a hiatal hernia repair, the opening is made smaller, and the esophagus, stomach and the junction between them is returned to the proper location to minimize-eliminate reflux.

2015 Back on Track or A New Start after Weight Loss SurgeryExclusive Member Content

January 08, 2015 8:37 pm

Hernia Repair And Weight loss surgery

December 22, 2014 3:35 pm

Patients having weight loss surgery (WLS) either primary or revision are sometimes also diagnosed with having a hernia. Whether a hernia can be repaired concurrently with WLS or not, depends on the type of the hernia and also type of weight loss surgery.

The 2 most common hernias encountered in weight loss surgical patient’s are 1.Ventral (incisional), or 2. Hiatal hernias. Ventral hernia refers to defects or weaknesses of the abdominal wall. If this involves a previous midline incision then an incisional hernia is diagnosed. These hernias may present with any or all of the following findings; protrusions or bulging of the anterior abdominal wall tissue through the abdominal muscle cavity, abdominal pain, and nausea and/or vomiting.

Hiatal hernias are located inside the abdominal cavity at the junction of the esophagus and the stomach at the level of the diaphragm. This condition is where the upper portion of the stomach this is usually located in the abdominal cavity has migrated through the esophageal hiatus into the chest cavity. These hernia’s usually present with reflux, episodes of nausea and are quite frequently seen in patients with experienced complications of the LAP-BAND.

The surgical treatment of these hernias are very different:

Ventral hernia repairs may require mesh placement. There are different mesh products that are available. Some are made with non absorbable material and other are absorbable- biologic material that last long enough to allow incorporation by the patients own tissue. In general, when a mesh is used, the incidence of hernia recurrence goes down significantly. However, there is an increase in complications associated with the use of mesh. These may include infection of the mesh, indications of synthetic material, and serum and rejection indications of non synthetic material. To add another layer of complexity, when the hernia is encountered at the time of weight loss surgery, especially when the GI track has to be opened ( in the case of duodenal switch, revision from a failed gastric bypass with a duodenal switch) then it is recommended that no mesh be placed because of the high incidence of mesh infection or the associated complications. In extreme cases where the abdominal wall cannot be closed, biologic meshes may be used with the understanding that a repeat hernia repair may be required at a later date.

In my practice, Hiatal hernias are always repaired at the time of the weight loss surgical procedures. Depending on the type of the weight loss surgery the patient has had previously, the type of the hernia repair, and whether or not a mesh needs to be utilized, and the amount of stomach and fundus remains for the repair, will dictate how the Hiatal hernia is repaired.

Additional information regarding hernias in a newsletter.

Erosion of Gastric Band

November 30, 2014 5:03 pm

Gastric bands are restrictive rings placed around the top part of the stomach, close to the junction of the esophagus. Their mechanism of action is to create a small tight band to restrict the flow of the food into the stomach. The theory has been that the band will decrease the time food travels down past the narrowing thereby eating less with the end result of weight loss. One of the many complications from the band is erosion of the band into the lumen of the stomach. This results in the patient presenting with nausea, vomiting and some patients develop abdominal accesses. This may present itself with symptoms of abdominal pain, fever, and redness at the port site under the skin.

The treatment for this is urgent removal of the band and repair of the erosion/ulceration. Patients who are contemplating a revision to another weight loss surgical procedure are best advised to stage the procedure because of the potential for leak from the repair site. Almost all of these procedures can be done laparoscopically.

Adjustable Gastric Band Easily Reversible?

November 24, 2014 3:25 pm

The Adjustable Gastric Band (AGB) procedures have been advertised as “easily reversible” minimally invasive procedures. A point of interest is why doesn’t anyone ask the question, “Why would a successful device and/or procedure need to be revised or removed?”

The long term success data shows that the AGB procedure is the most inferior of all bariatric procedures. It is important, that when looking at the published data, special attention is given to the definitions in that particular study. An example would be that if a study defines “successful outcomes as weight loss for 30 days!” then all procedure will be successful.

The following is an example of a patient who had the Lap Band (R) a several years ago in another institution. She was seen for surgical follow up with minimal weight loss over a short period of time. She then developed the typical complications of the band, namely the upper abdominal pain, reflux, inability to swallow solids, persistent nausea and vomiting. Her symptoms were all “worked up” and was told that all the studies were normal. All of her symptoms were contributed to her eating habits, even though they persisted after the Lap Band (R) was completely empty.

The patient then presented n our office for a second opinion. After being seen in our office and having a full work up, she had the Lap Band removed and was revised to a Laparoscopic Sleeve Gastrectomy. She had complete resolution of all of her prior presenting symptoms.

Adjustable Gastric Band Easily Reversible?

Pictured is the LapBand being dissected. There is significant scarring that has to be dissected to expose the band.

With the band removed a very thick band of scar tissue is exposed. This is a typical outcome- and it explains why most patients continue to experience the same symptoms even with the band completely empty.

The thick scar tissue must be dissected and removed to allow for the underlying tissue to return to near normal anatomy. The scar tissue act like a restrictive band. If this scar tissue is not removed the patient will continue to have problem after the band is removed.

Hopefully this will reassure patients who are having problems with the band after it’s reservoir is emptied. Scar tissue formation under the band is most likely the contributing factor to the continued and significant symptoms of abdominal pain, nausea, vomiting, and reflux. If you are having continued symptoms after your band has been deflated seek other surgical opinions.

Holiday Survival Tips by: Marylin Calzadilla, Psy.D.

November 17, 2014 8:23 pm

The holidays are almost here, and it’s a time of year that traditionally involves spending much time with loved ones as well as engaging in one of America’s greatest pastimes, eating. For the most people, holiday memories are strongly tied to traditional dishes and treats – turkey and ham, stuffing, mashed potatoes, and pie. But for those who have had weight loss surgery, or even if you are simply trying to be conscious of your health and weight, it is important to step back and think about the holidays from a different perspective. Below are six ideas not only for survival but for success this holiday season.

REFLECT

Think about what the holidays truly mean for you, and take the time to ask yourself what you want from this holiday season. Most of us get caught up in the rat race and never really stop and think what it’s all about. Vast amounts of money are spent on marketing campaigns aimed at luring us into shopping malls and grocery stores to buy the “indispensable” items of the holiday. Rather than get caught up in the hustle and consumerism of the season, I encourage everyone to stop and ask themselves what they’re truly wanting from the holidays. For some it may be spending time with those they care about, for others it may be to take time for oneself. Write down your goals on an index card and post it in a prominent place at home or at work as a reminder of what your holidays are going to be about this year.

SUPPORT, SUPPORT, SUPPORT

Tap into your support network. We know that strong, available support networks are key to long-term weight loss success. Often we are afraid to ask for help as if requesting assistance were symbolic of weakness. Often we have a double standard when it comes to support. We like helping others yet dislike asking others for help. Just as it feels quite rewarding to help someone that you care for, let the individuals in your life be there for you. Allow yourself to talk about your feelings, share your experiences, both positive and negative. There is also no better time to attend support group meetings. You can gain extensive comfort being around those facing similar issues. You can also learn from their mistakes as well as their successes.

ALLOWANCES

It’s difficult to achieve success if you feel deprived all the time. You may want to think about the dishes that are truly special to you and allow yourself to consciously indulge in a treat, if it’s appropriate for your level of post-operative diet. If you look forward to Aunt Marie’s delicious sweet potato pie every Thanksgiving, then allow yourself to enjoy this once-a-year tradition. Don’t tell yourself you will never be able to eat your favorite foods again. The bottom line is that long-term success with weight loss is about quality and quantity. Allow yourself to savor each and every bite, and remember portion control. Also strike a deal with yourself to manage any extra calories you’re taking in with increased exercise or careful eating on other days.

KEEP ACTIVE

Make a realistic exercise plan and stick to it. It’s easy to forego exercise during this busy time of year, but you shouldn’t compromise on your health. You will be spending more time around food and probably consuming a little more than you typically do. Sticking to your exercise routine will help you to indulge without feeling guilty and will allow you to get through the holidays without losing your hard-won progress on your weight loss. Plus, exercise will help you keep your energy and endorphins up so you can get everything done and feel good while you’re doing it.

CREATE

Spend some time researching new bariatric friendly recipes. You might actually really enjoy the process, and it’s also an opportunity to introduce some healthy alternatives to friends and family. The truth is, everyone is thinking about smart food choices these days, and people will appreciate a tasty, healthy alternative to the usual holiday fare. At the very least if you prepare a nutritious side or appetizer for a social gathering, you’ll know that there will be at least one healthy dish for you to eat.

PLAN ACTIVITES

Most holiday time is spent around the kitchen and the dinner table, but don’t be afraid to change it up. Create some fun activities your guests can engage in. Some friends of ours host a karaoke contest after their Thanksgiving meal. Other families go out for a walk, play charades, or even have contests on the Wii, Xbox, or any other home gaming system. Don’t be afraid to create a new tradition that gets everyone laughing, moving and having a good time.

Integrating some of these ideas can help keep you, your goals and the holiday season on track, healthy, and happy. All of the above tips may need to be adjusted depending on your situation and post surgical status.Best Wishes,
Marylin Calzadilla, Psy.D

Shared Success Story: Krystal U. Had a LapBand to Duodenal Switch Revsion

November 13, 2014 6:23 pm

Another amazing and emotional success story by Krystal Unruh. Krystal we celebrate you and your successful LapBand to Duodenal Switch revision. Thank you for sharing with us all.

Optimizing Pre-operative Health Status

November 12, 2014 1:23 pm

The outcome of any weight loss surgery is dependent not only on the operation but also the extend and depth of preparation before surgery and adherence to the post operative recommendation. The operation should be considered a planned injury to the body. We should enter the operating room in the best physical and mental condition possible to secure the best possible outcome. Optimizing your Pre-operative health status is the best plan for going into surgery in the best shape possible. Here are some basic steps to maximize the odds for a good outcome. Physical preparation:

Maintaining a healthy diet
Cessation of ALL tobacco and alcohol use
Do not use NSAIDS prior to surgery or after surgery until cleared by surgeon
Getting plenty of rest
Staying Hydrated
Pulmonary embolus prevention exercises such as ankle circles and point and flex toes
Maintaining or starting a regular activity level. Any amount of increase in activity will benefit you after surgery. Walking, squats, lifting weights with arms
Full laboratory blood studies and vitamin levels as ordered by the surgeon
Start and optimize your vitamins, calcium and other mineral and supplements. Vitamin D deficiency increases surgical complications. (Another Vitamin D article)
Manage preexisting health conditions (diabetes, sleep apnea, high blood pressure etc..) Follow instruction in regards to what medication to stop or continue before surgery i.e. Aspirin, blood thinners, medications that interfere/interact with anesthesia, etc.
Two forms of Birth Control if indicated.

Mental preparation:

Have a clear understanding of the procedure
Study all information provided to you regarding your surgery
Remember that surgery is one of many tools to assist in weight loss and improved health. It does not fix other issues.
Realistic expectation of the outcome of surgery
The role of family involvement for support
Be prepared with all the purchases for the post operative diet, vitamin and mineral supplements.
There is also a number of other variables that will improve the long term outcome of the weight loss surgery:
Investigate Protein Supplements for the highest bioavailability
Try and eat whole, unprocessed foods
Read labels on all food items
Look for high protein recipes
Network with supportive people who will provide a positive influence
Long term success also depends on:
Maintain daily protein requirements
Maintain daily vitamins, calcium, minerals and other supplements
Routine follow up with your bariatric surgeon.
Routine laboratory studies to surveil vitamin and mineral levels.
Get your medical advice from your surgeon.
Get suggestions from other patients. Do not confuse this with medical advice.

Weight loss surgical procedures are not an easy way out. On the contrary, weight loss surgical procedures are complex operations, from technical, metabolic, nutritional and psychologic perspective. A patient has to be prepared to deal with all aspect of the surgery for the best possible longterm outcome.

Shared Success Story: Patricia Y. Had a LapBand to Duodenal Switch revision

November 04, 2014 3:16 am

Patricia’s success story is truly inspiring and emotional. Please take a moment to celebrate her success by watching video about her journey and revision from LapBand to Duodenal Switch. Thank you Patricia for sharing you journey with us.

Patricia Y.