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It's been a long time since I've posted something about my own WLS journey, so I figured this is a good opportunity to talk about what's been going on with me.

For those of you who don't know my story, here it is in a nutshell: I was scheduled for an open RNY at the end of July with Surgeon #1, who cancelled my surgery shortly before the scheduled date, because he abruptly stopped doing RNYs. Having been told that there was no other WLS surgeon in Tucson who was covered by PacifiCare (my insurance carrier), I went through the re-approval process for a laparoscopic RNY with Surgeon #2 in Phoenix (two hours away), waited for an answer from August to the beginning of October, and was then denied on the grounds that Surgeon #2 was outside of my local provider network. As a stroke of good fortune, I learned that my post-cancellation phone call to Surgeon #3's office in July actually resulted in his contracting with PacifiCare for WLS, so I did have a local option. I decided to go with Surgeon #3 (local) instead of appealing PacifiCare's denial of Surgeon #2 (out-of-town). Are your heads spinning yet?

Surgeon #3 is Dr. Patrick Chiasson at Northwest Medical Center here in Tucson, which has preliminary approval as a Bariatric Center of Excellence and should have a formal designation within a few months. Dr. Chiasson and his partner, Dr. Burpee, specialize in minimally invasive surgery and do all of their procedures laparoscopically. They are also the only surgeons in Arizona who are performing Vertical Sleeve Gastrectomy ("VSG" or "the Sleeve") bariatric procedures. They believe that the VSG will replace the RNY as the gold standard of WLS within a few years, and their surgical practice is now about 55% VSGs. I have spoken with many of their patients in my WLS support group and have been following Teenieleenie's journey here on TT as well, and so far, I've heard overwhelmingly positive comments from people who are anywhere from newly post-op to well over a year out.

While preparing for my required endoscopy recently, I had to go off my twice-daily dose of Diclofenac Sodium (generic form of Voltaren), an anti-inflammatory drug that keeps me functional. I had a huge, excruciating gout flare-up in both feet and ankles, the right knee, and my left hand. I was literally unable to walk and was bedbound, in agony, for a week before my procedure. As soon as the endoscopy was done, I started back on my NSAIDs and got an injection of a corticosteroid from my new rheumatologist. The need to continue taking anti-inflammatories is one of the reasons Dr. Chiasson has urged me to consider having VSG instead of RNY.

I'll briefly explain what the VSG entails. The VSG is a strictly restrictive procedure with no bypassing of the intestines. Basically, a significant portion (75% or more, depending on the surgeon) of the lateral stomach is completely removed, leaving a small vertical "sleeve" of a stomach, about the size and shape of a ballpoint pen, which retains its original connections to the esophagus and small intestine, still produces digestive juices (stomach acid), but does not produce gherelin, the "hunger hormone".

Originally, the VSG was used as the first stage in a two-stage WLS process for the "super super obese" (BMIs above 60, like mine was at my highest weight of 540) because it was shorter, simpler, and safer for high risk patients than an RNY. After significant weight loss, VSG patients could then have second stage surgery, a conversion to RNY or Duodenal Switch (DS), to get them to goal. Over time, WLS surgeons performing the VSG found that it was successful also with patients with lower BMIs and could be used alone, without any second stage procedure, to effectively lose excess weight. Weight loss with VSG has been shown in recent studies to be superior to that with the LapBand and comparable to that with RNY.

Because there is no intestinal bypass, however, there is no malabsorbtion of food and thus a much lower risk of malnutrition than with the RNY (on the other hand, there is no "dumping" if sugar is consumed, which could be problematic for those patients who need that extra incentive to avoid sweets). Because there are normal digestive juices and intestinal absorbtion, normal medications, including NSAIDs and other anti-inflammatories, can be taken orally as needed, unlike with the RNY. Unlike the LapBand and RNY, the VSG is completely irreversible, but studies with three years of data are showing that the VSG has far fewer post-op complications, such as strictures and ulcers or uncontrolled weight loss from malnutrition, so reversals would be rarely, if ever, necessary.

Although partial or full gastrectomies have been performed on stomach cancer patients and people with severe bleeding ulcers for over 100 years, the VSG has only been performed as a bariatric procedure for about three years. Because there are no five-year studies of VSG yet, insurance companies consider the procedure "experimental" and normally will not cover it (they are only now starting to cover LapBands, so it could take a while!). The VSG is actually less expensive and time-consuming to perform than the RNY, requires a shorter hospital stay, and will likely result in fewer post-op problems that must be corrected, so insurance companies could save a great deal of money once they start approving the surgery as an alternative to RNY. Dr. Chiasson has been working with the new Medical Director of PacifiCare, providing educational materials, tours, etc., in hopes that PacifiCare will start covering the procedure.

As it stands now, I am waiting for Dr. Chiasson's office to review my now-massive file and determine whether it has everything it needs to submit me for insurance approval - I think everything has been done (and re-done, and done again), so I hope it will be soon. I have authorized Dr. Chiasson to submit me as a VSG to see what happens. I am hopeful (there are a mother and daughter on another forum who have PacifiCare in California, and they got approved for VSGs even though their policies normally excluded that procedure) but realistic - I know PacifiCare will likely deny this "experimental" procedure despite all of Dr. Chiasson's educational efforts.

If PacifiCare denies the VSG, then I will have Dr. Chiasson re-submit me for approval as an RNY and look at options for financing the $18,000.00 cost of self-pay for VSG. It's a tough choice - I have come to believe that the VSG is a better option for me because of the medication and nutrition advantages, but don't know if I can stomach (pardon the pun) financing such a large sum when my insurance will cover the current gold standard of bariatric surgery, a procedure that I've been preparing for for almost a year...

So, that's what's up with Eric!

Let me start by breaking the news that I finally learned this morning (10/2/07) that after sitting on my file for more than five weeks, PacifiCare has denied my pre-certification for Roux-en-Y ("RNY") gastric bypass surgery with Dr. Juarez in Phoenix, on the grounds that Dr. Juarez and St. Luke's Medical Center are outside of my "Metro Tucson" service network and are therefore excluded from my coverage, even though they are PacifiCare-contracted providers. The doctor in the Medical Management Department who wrote the denial letter informed me in the letter that I need to be referred to a surgeon and hospital in Tucson, "including St. Joseph's", which is an unintentional joke that fails to amuse me. Despite my request to Dr. Juarez and his staff that the re-authorization dictation specifically explain how and why I came to be a patient of Dr. Juarez and that there was no longer a covered Tucson surgeon available for my RNY, they appear to have submitted me merely as a first-time pre-certification patient, and PacifiCare apparantly denied me thinking that I'm an idiot who doesn't know that he's supposed to use doctors in his own city. When my first surgeon abruptly stopped doing RNYs at St. Joseph's in July (he is the only Tucson surgeon who does WLS there) and cancelled my surgery less than two weeks before the scheduled date, I scrambled to find a new surgeon to start the process again. I called PacifiCare the next day and spoke to the first in a long series of moronic (harsh, but accurate) customer service agents, who told me that there would be no problem getting a prior authorization in the "Metro Phoenix" network if there was no covered WLS surgeon in the "Metro Tucson" network for me to use. I eventually chose Dr. Juarez in Phoenix because of his reputation and experience and because I did not believe that there was an available alternative in Tucson who was covered by my insurance, with the possible exception of Dr. Monash, a new and MUCH less experienced associate of Dr. Schwartz. My former surgeon, Dr. Schwartz, is one of only three bariatric surgeons presently practicing in Tucson, although Dr. Monash and Dr. Lee (who have both just completed bariatric fellowships) are expected to start practicing RNY in town soon. Apart from Dr. Schwartz, there are two respected, experienced local bariatric surgeons, Drs. Chiasson and Burpee, in partnership on the other side of town, whose program at Northwest Medical Center is in the process of earning a Center of Excellence designation. I have met a number of their patients, who are very pleased with their surgical skill and their program. Drs. Chiasson and Burpee were my first choice after the cancellation by Dr. Schwartz, based on what I'd heard about them and the fact that they were local, but I had understood from my original WLS referral process in January that PacifiCare didn't cover them. I looked again in my benefits manual, and was delighted to see their names under "Abdominal Surgeons - general", so I gave the office a call to see if they were covered for RNYs. I spoke with Sonia, their office coordinator, and she told me that PacifiCare would cover Drs. Chiasson and Burpee for general abdominal surgery, but not RNY. She confirmed that PacifiCare patients used to have to go to Phoenix for their RNY surgeries until Dr. Schwartz came to town in 2006, and said that they'd probably have to start going back up to Phoenix since Dr. Schwartz had switched to only doing LapBands. So, I started the RNY ball rolling again with Dr. Juarez, and another moron customer service agent from PacifiCare told my referring Primary Care Physician that there would be no problem with that, because Dr. Juarez would not be considered "out-of-network", because he used to do all of the Tucson RNY surgeries.... After the cancellation, I stopped attending Dr. Schwartz's WLS support group (actually for a variety of reasons, not the cancellation itself) and started attending the two TUSWLS groups instead, which are run and attended primarily by Chiasson and Burpee patients, but also some Juarez and Schwartz patients as well. After I had already had a consult, seminar, and six-hour block of "ABC" classes at St. Luke's in Phoenix and started the re-approval process with Dr. Juarez, I met Dr. Burpee at one of the TUSWLS support group meetings at Northwest Medical Center. When I introduced myself as a Juarez patient and mentioned my cancellation by Dr. Schwartz, Dr. Burpee said "Oh, you're the one who called! After you called, we got to thinking that there was no reason for PacifiCare not to be covering us for RNYs as well as our other surgeries, so we contacted them and learned that they will cover us now for RNYs. You could have had the surgery with us after all..." "Great," I thought "now you tell me!" As it turned out, Dr. Chiasson had happened to overhear Sonia talking to me on the phone that day, and that conversation got him to call PacifiCare and confirm RNY coverage, but since I hadn't given the office my name or number, they had no way to contact me to tell me the news... During these last five or six weeks before today's denial letter, PacifiCare remained utterly silent as to the status of my re-approval (except for repeating "it is in the hands of our Medical Director" like a moron mantra) and stonewalled all attempts to gain information from the Prior Authorizations department. I have spoken to no less than 12 different customer service agents at different times, and have gotten 14 different answers, sometimes with snotty attitudes thrown in for good measure. A select few were pleasant and more knowledgeable than their moronic littermates, but the experience of dealing with PacifiCare has been horrendous overall, and I am a lawyer used to negotiating the bureaucracies of large organizations - I can only imagine how confusing and frustrating these tactics must be for the average consumer! For the record, the consumer advocate for the Arizona Department of Insurance was wonderful (and a RNY patient herself), but couldn't help me get an answer because the State has no jurisdiction in disputes involving health insurance of federal employees. The United States Office of Personnel Management, which does have jurisdiction, was as bad to negotiate as PacifiCare, required four calls with the attendant moron-to-moron transfers and requisite disconnects, and when I finally learned who the "right person" for this problem was, she has never returned my calls! Fast forward to today. After Dr. Juarez's office faxed me the denial letter, I called Emily, Dr. Schwartz's office coordinator, to get a letter from that office stating that Dr. Schwartz is no longer performing RNYs at St. Joseph's or anywhere else (apparently PacifiCare is not aware of this), so that I can include that letter with my appeal to PacifiCare, if I decide to go that route. I also tried to call the doctor in the Medical Management Department who wrote my denial letter to see whether I could explain the situation personally without initiating a formal appeal - no dice - moron # 12 told me Dr. Denial doesn't take any calls or messages, even from medical providers! Any appeal will have to be the formal, written kind. I won't bother with the laughable option given to make an "informal verbal appeal" via the customer service agents (I'm not kidding - it's in my denial letter), given the facts of my case and my now complete distrust of dealing with any PacifiCare customer service agents ever again... I also called Sonia at Drs. Chiasson and Burpee's office and confirmed that yes, indeed, they are contracted with PacifiCare to do RNYs and that my call in July was the catalyst for that. I signed up for one of their mandatory information seminars next week, in case I decide not to pursue an appeal to use Dr. Juarez as my surgeon, and instead seek re-approval with one of those doctors. I can schedule a consult with whichever one of them I prefer once I've attended the seminar. They are less experienced than Juarez, but were trained in part by him (or so people have told me) and are well out of their learning curve (almost 500 laparoscopic RNYs each), and it would be great to be able to stay in town for surgery and aftercare rather than go to Phoenix. I know, I know - things happen for a reason and God works in mysterious ways!

 It's ridiculous that PacifiCare has taken this long to re-approve me (they received my file from Dr. Juarez exactly one month ago today, for crying out loud!), but I've given up on "rattling cages" by calling them directly - it doesn't help and only serves to irritate me. I have spoken to different PacifiCare customer service agents no less than seven times in the last month, and have never gotten a single piece of useful information (well, one piece), much less consistent answers, out of any of them.

One told me that she wasn't allowed to give me any information at all, apparently to protect my privacy from myself. Another told me (wrongly) that I was approved, but only for a 30-day window from August 24 to September 24. Two different others told me they couldn't decipher the medical terminology to tell me what my electronic file indicated. Two others told me (correctly) that my file was still under review by the Medical Director of Prior Authorizations and to contact my surgeon for the status of the approval.

The Prior Authorizations department will only speak with providers, not patients, and I had trouble even getting a PacifiCare CSA to give me the phone number of the department (one finally did give it to me) that is apparently holding up this process, in order to allow me to find out for myself what is taking so long. I called Prior Authorizations myself, and, as the CSAs had warned me, they didn't want to speak to me because I was a member, not a provider.

I went into my explanation of why I was calling on my own behalf, and then was placed on hold for a really long time, with annoying music repeating again and again. The hold lasted so long that I placed the phone on speaker and proceeded to go about my business for about 20 minutes, rather than just sitting there with my shoulder cramping and my eyes glazing over. Finally, the Prior Authorizations rep came back on the line and told me (ta da!) that my file was in the hands of the Medical Director, that there was no other information that they could give me about its status, and that I would have to have my surgeon's office get in touch with the Medical Director.

Getting answers from my surgeon's office has not been easy either. Colene, the regular authorizations person in Dr. Juarez's office, went on maternity leave last week. Nicole, the person who is handling authorizations in Colene's absence, told me last Wednesday that she had just talked to PacifiCare, reminded the Prior Authorizations department that this was a re-approval with only a change in surgeon, and asked them to expedite the authorization request, since the Medical Director had had the file for almost four weeks.

Nicole asked me to call her on Friday to see if anything had changed. When I called early on Friday afternoon, she had already left for the weekend. I left her a message at that time. I called again Monday, and was told that she was out of the office for the day. I left another message. I called again today (Tuesday), and learned that she is still out of the office until tomorrow...

For those of you who don't already know my story and why this is becoming so frustrating, let me explain that my first approval took two working days! I had an appointment with my original surgeon (bless his heart!) on June 7, before he submitted his dictation to PacifiCare, and received word from his office that I was approved on Monday, June 11. Surgery was scheduled for July 31, but cancelled by the surgeon (bless his heart!) on July 18. I had to start the insurance approval process over again with the new surgeon in August, but was able to use all of my evals, etc. from the first approval, so I was anticipating an easy re-approval process and hoping for a surgery date in late October or November. Now I'm thinking December or January!

As I stated in the previous post, I am doing my best to "let go and let God" in this situation - doing as much of the "footwork" as I can do and not trying to control the outcome. I am treating this re-authorization process as an opportunity to practice patience and acceptance of the things I cannot change (saying the Serenity Prayer a lot!), and am focusing my energy on other parts of my life that are within my control, such as eating less (which has been a problem lately), going to my water cardio class at the gym and getting more exercise, and dealing with work and home projects.

It's not easy to "turn it over" and my patience is wearing thin, but I don't really have a choice, if I want to keep some level of serenity - I can make calls every day to PacifiCare, but it does no good unless the right department will speak to me. I can call the surgeon's office every day, but it does no good if the people I need to speak with aren't there, and can't do anything to speed up the process anyway. All I can do is the next right thing, whatever that may be, and know that this surgery will happen whenever it's meant to happen...

Dr. Juarez's office submitted my case for approval last week. I called the office to check the status on Wednesday, and Colene, the surgeon's authorizations specialist, told me that PacifiCare had just confirmed that my file was on its Medical Director's desk and that they would hopefully have an answer by the end of this week.

I called PacifiCare directly this morning for an update and talked to a very nice but not terribly helpful customer service representative. She confirmed that an authorization for surgery had been requested by Dr. Juarez's office on August 24, but she couldn't interpret all of the medical lingo (!?!) on the last page of my computer file to tell me whether it was approved or not. She suggested that I call my surgeon's office.

I left a message for Colene this morning, but having heard nothing, I had the bright idea of calling PacifiCare back, to see whether a different CSR would be able to help me more than the first one, but, of course, I got the same one! So, rather than chance a third call with her, I decided to hang tight.

Colene just returned my call this afternoon and told me that the August 24 date the CSR was seeing was the date my file went to PacifiCare, and that the file is still in the hands of the Medical Director. Given that it's now 3:30 p.m. before a three-day weekend, I don't think anything will be done on my case today and I'll have to wait until at least Tuesday for any new info.

I'm not sure why this is taking so long - I know approvals can take weeks, and I fully expected that kind of wait the first time, but my first approval took just a few days. Dr. Schwartz saw me for the final pre-dictation consult on Thursday, June 7, and PacifiCare approved me on Monday, June 11 - only two working days later.

I am hoping that I will be re-approved SOON, but am trying to practice patience. I know it will happen when it's meant to happen, but the walls are starting to look pretty climb-able!

When I met with the new surgeon on Friday, August 17, we discussed my goal weight. I told him I wanted to weigh 200, which is what I weighed in late high school and college, a weight at which I looked and felt good. Although I was definitely thin ("bone thin" as one of my friends described me) at that weight, 200 is at the top of the "normal" range of BMI for someone of my height - 205 is "overweight". Dr. Juarez was horrified when I told him my goal and told me that he sees 250 as a healthy weight for me, and that 200 is much too low for my height and frame size ( I really am big boned - I wear size 16 shoes!).

I really can't see myself being happy at 250, especially since I will eventually need a full knee replacement on both knees, which will require me to be under 250, so I have set a personal goal of 225, for a couple of reasons. First, it is a midpoint between my surgeon's goal and my personal ideal, an ideal that I admit may no longer be applicable, but still sticks in my head. Second, when I had a thorough body composition analysis done in 1999, I found out that my lean body weight (basically just the weight of bone, organs, muscles, and skin) was 207 pounds, and that I (and everyone else) need 20 pounds of body fat to protect my organs, so I was told that my appropriate weight, absent any added muscle, would be 225-230. So, I will keep 225 as my goal, and if I get there and find it's too low, I'll adjust upward. If I find that the BMI chart is right (which I doubt), then I will adjust downward. Either way, I've still got a long way to go!

I met with Dr. Hilario Juarez at St. Luke's Medical Center in Phoenix yesterday and attended the mandatory basic introductory seminar at St. Luke's Bridges Centre for Surgical Weight Management (a Bariatric Center of Excellence, and yes, the Bridges Centre uses the British spelling of "center" in its name - it's not a typo). Here's the latest:

First, let me state that Dr. Juarez was perfectly pleasant and answered all of my numerous questions with patience and courtesy, without appearing rushed, despite an obviously busy schedule. Although I had concerns about his bedside manner before meeting him, I had no complaints afterwards!

I provided all of my records from my previous surgeon, but somehow the letter of cardiac clearance that I gave to Dr. Schwartz's office did not get scanned into my file and was missing from the packet I brought to Dr. Juarez. I will need to give Dr. Juarez another copy, so I called my cardiologist's office after leaving St. Luke's and am in the process of getting another letter from him. Yes, I will make a copy for my own records this time as well - I normally know better!

I will also need a letter of pulmonary clearance, which Dr. Schwartz did not require, so I have contacted my PCP's office for a referral to my pulmonologist. Once I have the referral, I will make an appointment with the pulmonologist and get a clearance letter from him (yes, which I will also copy for myself!) a.s.a.p.

The Bridges Centre requires ALL of its patients to attend a series of three two-hour classes known as the "ABCs", which deal with nutrition, psychological issues pre- and post-WLS, pre-op preparation, etc., and are normally offered one class per month, to be spread out over three months. For out-of-town patients, the Centre offers a special six-hour class that combines classes A, B, and C into one session.

I had hoped not to have to do the ABC classes at all, given my situation, but the director of the Centre explained that EVERYONE, no matter how well-informed they are or how far they went in the process with another surgeon, is required to attend the three classes - part of the Centre's designation as a Center of Excellence is the extensive teaching that the Centre does with every patient before surgery.

I will be going back up to Phoenix on Tuesday afternoon for the class, which will run from 3:00 to 9:00 p.m. I will drop off my letter of cardiac clearance personally to the surgeon's office before class starts. Well, if I have to do the class, at least I'll get it out of the way all at once, and quite soon too...

Dr. Juarez's office will probably submit me for approval (re-approval) by PacifiCare on Wednesday. Once I am approved, we can schedule a new date. Dr. Juarez told me we can set a surgery date as soon as six to eight weeks after approval, which is fine with me. I am looking for a date in late October or November, since all of the work that I pushed off to accomodate my original six-week medical leave will be done by mid-October. My weight yesterday was 453.4, which is 33.1 pounds lighter than I was at the beginning of July. I have been trying not to waste the weight loss time I have lost from the cancellation of my surgery, and am very pleased!

Dr. Juarez has done over 3000 RNYs, around 1000 open and over 2000 lap. He told me that he very rarely has to convert lap to open and has not had a conversion for a year or year-and-a-half, the last time with a patient who had lots of adhesions from multiple abdominal surgeries. He opined that he can do mine lap, despite my size, and he estimated my surgical time at an hour-and-a-half, which is a relief. The primary reason that I was fine with Dr. Schwartz doing my RNY open (that was the only way he did them) was the shorter op time and the shorter time under anaesthesia, but Dr. Juarez's lap surgery time is very close to Dr. Schwartz's open surgery time, so that is no longer a concern.

As a side note, here is an interesting comparison: the Bridges Centre has its post-op patients do full liquids immediately (as tolerated) rather than starting with a week of clear liquids before progressing, as Dr. Schwartz's program does...

I have not heard back from my surgeon's office regarding the LapBand approval, but I already called PacifiCare myself this morning [Thursday, July 19] and confirmed that LapBand will not be covered under my policy. In addition, I re-read the parts of "Weight Loss Surgery for Dummies" dealing with LapBand and the numerous articles and surgeon's websites online dealing with the RNY vs. LapBand debate. I had done all this more than six months ago, when I eventually decided that RNY was right for me, but I did it again, just to make sure. As much as I would like a short, safe, easy, reversible outpatient procedure that doesn't have the same possible nutritional complications as an RNY, I remain convinced that the RNY will be the most effective for me short- and long-term, given my weight, BMI, and co-morbidities.

I explained the cancellation situation to PacifiCare and they recommended getting a new referral from my PCP, which I requested from him this morning. I will need a special preauthorization to see someone outside of the Tucson network.

I confirmed with PacifiCare that the Scottsdale Bariatric Center, one of the Centers of Excellence I was considering, under Dr. Robin Blackstone, would not be covered by my insurance. I called the clinic and learned that the surgery would be $26,000 self pay and they said I would have to start all over from the beginning and pay for all of the new testing, psych eval, etc., and that Dr. Blackstone is currently booked into February. I think not!

I went ahead and scheduled an appointment for a consultation with Dr. Hilario Juarez in Phoenix on August 17, even though I haven't gotten the referral from my PCP yet, and will attend his seminar at the Bridges Centre for Surgical Weight Management (another bariatric Center of Excellence) at St. Luke's Medical Center that same day. I will also probably arrange to meet with Dr. Jeff Monash once he comes to Tucson in August, to see what I think of him and whether I would prefer him to Dr. Juarez.

Sooo, that's where it all stands. I know things happen for a reason, which will someday be made clear, so I'm doing what's in my power to do and "letting go and letting God" for the rest.

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My world has been turned upside-down.

Last night [Tuesday, July 17], at my surgeon's WLS support group meeting, the new clinical coordinator told me that I would probably be one of Dr. Schwartz's last RNY patients. Not hugely surprising - I have known for a while that Dr. Schwartz greatly prefers doing LapBands (despite having done 600+ open RNYs) and has revamped his surgical program to focus on that surgery, including cutting back on RNYs, dramatically changing his website to show an emphasis on LapBand, and increasing his marketing by appearing in LapBand television commercials and on billboards all over town. The Carondelet Medical Group is even bringing in a new bariatric surgeon, Dr. Jeff Monash, who will handle only laparoscopic RNYs at another Carondelet hospital starting sometime in the fall, once he finishes his laparoscopic surgical fellowship in San Francisco in August, leaving Dr. Schwartz with a purely LapBand practice. All well and good - not really relevant to me or my surgery, or so I thought. Ha ha.

At 4:30 this afternoon [Wednesday, July 18], after having worked with my surgeon's office for the last six months, having arranged for six weeks off from work and worked really hard to clear my busy calendar and wrap up work before the end of next week, less than two weeks before surgery, one week from my pre-op teaching class with my surgeon, having completed pre-op testing last week, and having started my two-week pre-op liquid diet yesterday (after weeks of being really good at staying under 2000 calories per day to get ready for the 1000 calorie liquid diet), I got a call. Not from Dr. Schwartz himself - no, of course not. He had Laurie, his M.A., do it.

Laurie apologetically informed me that Dr. Schwartz will no longer be doing any RNYs, effective immediately. I will not be having an open RNY on July 31. The office instead will submit me to PacifiCare tomorrow for approval for a LapBand to see whether the insurance company will permit the change in procedure.

My PacifiCare FEHB (Federal Employee Health Benefits) written policy, effective 1/07, says it covers RNY only, but Laurie says that many companies have recently changed their policies to cover LapBand and that it's worth a shot - their office recently got LapBand approval for a federal employee with BC/BS, which used not to cover Lapband. If not, I will either have to finance self-pay or find another surgeon.

If I choose to find another surgeon, I can wait a few months until Dr. Monash's practice is up and running and have a lap RNY at a hospital across town instead of the open one less than a mile away (and have to redo every test and time off request), or I can seek approval for a Phoenix surgeon, such as Hilario Juarez (definitely covered by PacifiCare) or Robin Blackstone (not sure), which could possibly take place sooner, but would take place about two hours away and be hard to deal with for aftercare.

I am really disgusted right now, not just by the total change in my plans, but also by the fact that Dr. Schwartz made this announcement so soon before my date (why couldn't he just do mine on July 31 and be done with RNYs starting August 1?) and that he didn't even have the courtesy to talk to me personally. If I am approved for the LapBand, do I even want to have it done by someone who has behaved in what I consider an extremely callous manner? And will I have enough time to learn about a totally different WLS procedure, eating and nutrition issues, and its possible complications?

This timeline has been part of my signature on another forum, and I thought it would be good to put it into my OH blog:

referral to surgeon by PCP 12/7/06
consult with Clinical Coordinator 1/12/07
consult with Dr. Schwartz 1/26/07
first consult with Dietician 2/8/07
psych eval initial appt. 2/23/07
psych eval postponed to 3/23/07
psych eval postponed again - 5/7/07
psych eval second appt 5/14/07
psych eval third (final) appt 5/21/07
second consult with Dr. Schwartz 6/7/07
submitted to insurance for approval 6/7/07
approved 6/11/07
meeting with hospital dietician 6/27/07
therapist appointment 7/2/07
pre-op testing 7/12/07
therapist appointment 7/16/07
pre-op liquid diet begins 7/17/07
pre-op teaching/meeting with surgeon 7/25/07
surgery date 7/31/07
surgery cancelled by Dr. Schwartz 7/18/07
consult & seminar with Dr. Juarez in Phoenix 8/17/07
pre-op "ABC" classes in Phoenix 8/21/07
submitted to insurance for re-approval 8/24/07
RNY with Dr. Juarez denied by PacifiCare 10/1/07
seminar with Dr. Chiasson 10/11/07
consult with Dr. Chiasson 10/19/07
endoscopy (EGD) scheduled for 11/5/07

My surgery will be open. My surgeon, Dr. Monte Schwartz, only does open precedures, but his practice is branching out - some time in August he is adding another surgeon, Dr. Jeff Monash, who is finishing a laparoscopic surgery fellowship in San Francisco. Starting in August, patients will be able to choose which doctor and procedure they want.

I toyed with the idea of waiting until August in order to have a lap RNY instead of open, especially since shorter recovery time would mean less time off work, but for me personally, there may be more advantages to the open procedure despite the pain and longer recovery time. 

For example, the open is faster to perform, which means less time under anaesthesia - I had difficulty coming to after a lap appendectomy in 1999, when I weighed about 120 pounds less than I do now, so I am concerned about that. Also, Dr. Schwartz has told me that the incidence of leaks (e.g., between pouch and small intestine) is lower with open RNYs than with laps. Also, I'm sure Dr. Monash is great, but I already know Dr. Schwartz and his level of expertise, and have spent a lot of time talking to other patients of his about their experiences, so I'm more comfortable having him do the surgery. Plus, given the size of my torso, I'm not sure whether a surgeon could complete my RNY laparoscopically, without having to open me up...