For patients who have acquired weight following gastric bypass, we now offer the Restorative Obesity Surgery Endoscopic (ROSE) technique. This is an incisionless operation that returns the pouch and stoma to their pre-surgery sizes.
Surgeons construct and sew folds into the pouch to lower its volume and at the stoma to minimize its diameter using novel surgical instruments for gastric bypass revision. The treatment is carried done totally through the mouth, with no exterior incisions into the body.
How much weight can you lose with the ROSE procedure?
Patients who lost the greatest weight after their previous gastric bypass had the best outcomes after the ROSE operation. During the six months following ROSE, this subset of patients lost 29% of their extra weight.
Does insurance pay for second weight loss surgery?
- Conversion Surgery is a technique that allows you to go from one type of bariatric procedure to another. Lap band to gastric sleeve or gastric sleeve to gastric bypass are the only two treatments that can be converted. Both become permanent after that.
- Surgery to restore the effectiveness of the original bariatric treatment is known as revisional surgery. Revisional surgery is any operation used to treat failing weight reduction after a gastric bypass or gastric sleeve.
Insurance companies currently consider revisional surgery options to be experimental or investigational. The following are examples of revisional procedures:
Your insurance plan may not cover a second procedure. You’ll need to go over your plan to see what your coverage options are and what standards you’ll need to meet in order to be considered for another weight reduction procedure.
Does insurance cover Stomaphyx?
The procedure will cost anywhere from $8,000 to $13,000 depending on your surgeon and region of the country.
Due to the scarcity of research documenting the procedure’s outcomes, insurance companies rarely pay it. There are, however, a number of viable bariatric surgery financing solutions available to help pay for some or all of the procedure.
As previously said, we highly advise against doing this operation until more data confirming its efficacy and safety is available.
WHAT IS A ROSE procedure?
An endoscopic weight reduction therapy is a non-surgical weight loss treatment that uses an endoscope rather than exterior incisions (cuts). An endoscope is a thin, flexible tube used by doctors to examine your digestive tract. Endoscopic techniques are thought to be much safer than standard surgery.
Brigham and Women’s Hospital was one of the first sites to participate in the patient registry for this treatment, and it is now the only location on the East Coast that has been approved to conduct it.
Can you have gastric sleeve after gastric bypass?
A failed Roux-en-Y Gastric Bypass (RNY) can be reversed (taken down) and replaced with a vertical sleeve gastrectomy (VSG), commonly known as a gastric sleeve (RNY “converted” to VSG.)
From a technical standpoint, this technique is far more difficult than any of the two surgeries performed previously (primary bariatric surgical procedures as opposed to revisional procedures). It entails reconstructing the stomach, which must then be “sleeved,” as well as removing the roux-en-y limb of the jejunum and either removing it completely or reconnecting it with the rest of the intestines.
To fully reconstruct and safely sleeve the restored stomach, this must be done as an open (not laparoscopic) procedure in my experience.
Furthermore, because the risk of problems is considerable (up to 25% to 30%, or one in every three patients), patients who undertake this treatment should expect a longer recovery than they did with their previous procedure.
The first (main) bariatric surgery procedure. This includes leaks from the gastric sleeve, as well as mechanical and/or functional obstructions at the gastro-gastrostomy (stomach reconstruction site), the pylorus (which has been defunctionalized for a long time due to the RNY anatomy), and/or the reconstructed intestine after reconnecting the roux-en-y limb of the jejunum to the rest of the intestines.
Frequently, I will put a feeding jejunostomy tube as a precaution during the surgical surgery, to be used if the patient experiences one of these problems afterward.
My experience is that when patients recover from revisional bariatric surgery, they have a very satisfying weight loss and are pleased with the results.
Remember, just as the RNY failed over time due to a lack of related calorie malabsorption, the VSG is at danger of long-term failure, with the distinct prospect of weight regain, needing yet another bariatric surgical intervention. As a result, many patients who fail the RNY consider the Duodenal Switch (DS) as a revisional bariatric treatment with a far lower risk of weight gain over time than the VSG or the RNY.
Overall, revisional bariatric surgery is a much more complicated intervention, both from the perspective of the prospective patient in terms of deciding which procedure to undergo and from the perspective of the bariatric surgeon in terms of the nuances of the surgical procedure and subsequent patient management.
DISCLAIMER: The following educational advise is based on the complexity of your query and the information you’ve supplied. The following should never take the place of medical advice from your local doctors, who can assess you in person.
What is a TORe procedure?
Procedure to reduce the size of the transoral outflow The endoscopic procedure for transoral outlet reduction (TORe). The gastrojejunal anastomosis is plicated (Before) and reduced in size to 1 cm (After) using an endoscopic suturing method, restoring the restrictive component of the gastric bypass.
How long does it take for insurance to approve weight loss surgery?
A growing number of states have approved legislation requiring insurance companies to provide weight-loss surgery for people who fulfill the NIH surgical requirements. While weight-loss surgery is commonly covered by insurance, the approval process can be lengthy and complicated. Working with your surgeon and other professionals gives you the best chance of getting insurance coverage approved.
Steps to obtain insurance coverage for bariatric surgery:
- Most insurance companies are aware of the health risks associated with obesity and will cover the costs of surgical weight loss in qualified patients. Every insurance plan, however, is unique.
- We begin the process of obtaining insurance authorization once you have completed our preparatory program, satisfied all of your insurance company’s requirements, and the surgeon has cleared you for surgery. We start by submitting your medical records to your insurance company, requesting that they fund the procedure. The insurance company may take two to four weeks to react with a decision.
- Once we obtain permission or refusal from the insurance carrier, we will contact you. If the coverage is accepted, the patient is given a surgery date and a pre-op appointment. If coverage is refused, we investigate the cause for the decision and file an appeal with the insurance carrier.
What can I do if my insurance doesn’t cover bariatric surgery?
After you’ve weighed your alternatives and decided that bariatric surgery is the best option for you, you’ll want to know how you’ll pay for it. Many insurance companies acknowledge the importance of obesity and its health repercussions, and will pay for weight loss procedures if you meet plan-specific eligibility requirements.
How to verify your own benefits
Although the staff at your surgeon’s office will verify your benefits as a courtesy, it’s a good idea to call your insurance carrier to confirm coverage and restrictions. You can also read the coverage documentation that your employer and/or insurance company have issued to you.
You’ll want to know if bariatric surgery is covered; if it isn’t, it’ll most likely be included under “obesity” or “weight reduction surgery” in the plan’s exclusions. Bariatric surgery is commonly described as being covered if it is medically required, but this is only partially accurate because it must also be a covered benefit.
You’ll want to know what’s required once you’ve confirmed that your plan covers bariatric surgery. Each plan has its own set of criteria and regulations for determining medical necessity to your insurance carrier’s satisfaction. Although your carrier’s medical policy is the most typical place to obtain benefit criteria, your employer may have an addendum document (“summary plan document/description”) that explains extra or other requirements for particular treatments. Because the requirements of the medical policy are often superseded by a summary plan document, it’s crucial to know if an addition like this applies.
Medical necessity vs. coverage exclusions
Despite the fact that you may meet basic and widely accepted medical necessity requirements, your insurance company is not compelled to cover bariatric surgery. Your insurance will not consider you for coverage if weight loss surgical services are designated as an exclusion, regardless of your BMI or concomitant conditions. The denial rationale does not imply that surgery is not medically required, but rather that they do not give this form of coverage, for which there is no appeals process.
Cash paying for surgery
There are alternative solutions open to you if your insurance does not cover bariatric surgery. Consultations, nutritional counseling, pre- and post-operative tests, labs, and follow-up visits may be covered depending on the plan language, but surgery is not. Verifying your benefits will assist us in estimating potential costs for you during your appointment.
How to meet insurance criteria
You’ll meet with a surgeon for a consultation once your benefits have been validated. Your height, weight, and BMI will be recorded, as well as any concomitant conditions and previous unsuccessful attempts at non-surgical weight loss. If your plan calls for a medically supervised weight loss program, you’ll meet with a dietitian on a monthly basis for the duration of your treatment.
Because a psychological clearance is the most common insurance criterion, you should make an appointment with a mental health professional who will assess your candidacy for bariatric surgery. It’s crucial to rule out psychological issues, any type of disordered eating, a lack of competence to provide informed consent, and a failure to follow pre- and post-surgical instructions.
Insurance authorization process
The authorisation process can commence if all pre-surgical and insurance requirements have been satisfied. Your pertinent medical records will be compiled and sent to the clinical review department of your insurance company. A determination can take up to four weeks, but it is more common to receive one in two weeks. You’ll be advised of the approval or denial once we hear from your insurer. Surgery can be planned or confirmed once you’ve gotten approval.
If your operation is denied, we will examine the decision and follow the measures provided by your insurance company. Denials can occur for a variety of reasons, including a lack of paperwork or a lack of agreement on criteria that are ambiguous or open to interpretation.
Appeals
Because appeals deadlines may be approaching quickly, it’s critical to properly evaluate denials.
As a first step in this procedure, a peer-to-peer option is usually provided. A peer-to-peer meeting is a prearranged meeting between your surgeon and the medical director of the insurance company to address the denial. When this conference is feasible, it’s quite beneficial since we can get precise input from a reviewing authority about what additional the insurance company expects us to provide or what they want you to accomplish in order to qualify. At the time of this debate, the rejection may be affirmed or reversed, but it’s usually just a tool for moving forward with the appeal.
If an appeal is necessary, we will obtain any additional documentation that was previously overlooked. If more tests or office visits are needed, they should be planned as quickly as possible to ensure that they are completed before the appeal time expires.
There could be several stages to the appeals process. A second- or third-level appeal can be requested if necessary, with the final step typically including submission to an outside party for review. Because external review organizations are not linked with our office or your insurance provider, they can conduct an unbiased assessment of your clinical documentation.
What can I do to ensure approval?
A patient health history questionnaire will be given to you prior to your session. Because it will be translated into your medical record, which will be evaluated by the insurance provider, it is critical that you fill this out entirely and truthfully.
Bring a copy of any paperwork (medical chart notes, personal records, logs, or receipts) from past weight loss attempts, whether by diet, exercise, or medical supervision, to be reviewed and scanned into your chart.
If you’ve had a previous weight reduction treatment, you should get copies of your operative report, as well as pre- and post-surgical visits, to demonstrate your commitment to follow-up and adherence to any suggestions provided by your previous practitioner.
The single most important thing a patient can do to increase the chances of their insurance company approving their claim is to follow the medical policy’s rules to the letter (or Summary Plan Document, if applicable). Medically supervised diets are generally need to be followed for several months and should be spread out by about 30 days. Failure to keep scheduled appointments for several months in a row will almost always result in denial, delaying surgery or forcing you to restart the prescribed regimen from the beginning.
How do I get approved for weight loss surgery?
You must meet the following criteria to be considered for weight-loss surgery:
- Have a BMI of 40 or more, or a BMI of 35 to 40 and an obesity-related ailment, such as heart disease, diabetes, high blood pressure, or severe sleep apnea.
- Weigh fewer than 450 pounds, which is the maximum weight allowed by hospital imaging equipment. A nutritionist can assist you if you need to lose weight to meet this criteria.
- Check to see whether your health insurance will fund bariatric surgery at UCSF if certain criteria are satisfied. Please be aware that we only accept Medi-Cal patients who are residents of San Francisco County.
What is the cost of a gastric sleeve revision?
However, the real question is whether or not a surgeon can make changes.
We like to have an upper endoscopy on our patients who have acquired a large amount of weight and aren’t nibbling on the improper meals in our practice.
If the endoscopy reveals a dilated pouch-to-small-bowel connection, we can conduct a revision by laparoscopically restricting the connection and pouch……we believe this is the only revision that is adequate.
It’s worth noting that if a patient has regained weight by nibbling on high-carb foods, there’s a good chance we won’t be able to help them.
If the endoscopy reveals no dilation, it is up to the patient to get back on track…
In terms of cost, if insurance does not cover it, it costs between $20,000 and $30,000 in our clinic, which covers the surgeon, assistant, hospital, anesthesia, and a year of follow-up….