If you do not have insurance, don’t give up! You still may have an option available in obtaining treatment. Simply become a cash patient. Pay for the surgery yourself. Some doctors can work with you on their pricing or payment plans. The benefit of paying for the surgery yourself is that you don’t have to wait for insurance approval and can usually have the surgery within 1-2 weeks of seeing the surgeon.

You may have to pay for your own weight loss surgery, but weight loss surgery is often covered by insurance. Even though in recent years, insurance companies have become more demanding in their screening of patients, the vast majority of surgeries are covered. If anyone, where you work, has had weight loss surgery, check with them about what experience he had with insurance coverage. You’ll get a sense of what, if anything, you may be up against. If you have the same insurance company as one of your friends but you aren’t on the same plan, your insurance could be entirely different. One company may list the surgery as an exclusion for its employees, while another company that uses the same insurance company may not. Just be sure to talk with your insurance company beforehand so you know what costs, if any, will be involved.

After your consultations are completed, and we get all reports it usually takes your doctor 1-2 days to send a letter to your insurance carrier to start the approval process. The time it takes to get an answer can vary from about 3-4 weeks or longer if you are not persistent in your follow-up. Most treatment centers have insurance analysts who will follow up regularly on approval requests. It may be helpful for you to call the claims service of your insurance company about a week after your letter is submitted and ask about the status of your request.

Payment may be denied because there may be a specific exclusion in your policy for obesity surgery or “treatment of obesity.” Such an exclusion can often be appealed when the surgical treatment is recommended by your surgeon or referring physician as the best therapy to relieve life-threatening obesity-related health conditions, which usually are covered.

Insurance payment may also be denied for lack of “medical necessity.” A therapy is deemed to be medically necessary when it is needed to treat a serious or life-threatening condition. In the case of morbid obesity, alternative treatments – such as dieting, exercise, behavior modification, and some medications – are considered to be available. Medical necessity denials usually hinge on the insurance company’s request for some form of documentation, such as 1 to 5 years of physician-supervised dieting or a psychiatric evaluation, illustrating that you have tried unsuccessfully to lose weight by other methods.

First, help us to get all the information (diet records, medical records, medical tests) together in your case, so the carrier cannot deny for failure to provide “necessary” information. Letters from your personal physician and consultants, attesting to the “medical necessity” of treatment, are particularly valuable – when one or several physicians corroborate the necessity of treatment, it will be hard for the carrier to contradict them.

When the letter is submitted, call your carrier regularly (about once a week), to ask about your status. You may also be able to protest unreasonable delays through your employer or human relations/personnel office.

Certain basic tests are done prior to surgery: a Complete Blood Count (CBC), Urinalysis, and a Chemistry Panel, which gives a readout of about 20 blood chemistry values. Often a Glucose Tolerance Test is done to evaluate for diabetes, which is very common in overweight persons. All patients but the very young get a chest X-ray and an electrocardiogram. Women may have a vaginal ultrasound to look for abnormalities of the ovaries or uterus. Many surgeons ask for a gallbladder ultrasound to look for gallstones. Other tests, such as pulmonary function testing, echocardiogram, sleep studies, GI evaluation, cardiology evaluation, or psychiatric evaluation, may be requested when indicated.

An accurate assessment of your health is needed before surgery. The best way to avoid complications is to never have them in the first place. It is important to know if your thyroid function is adequate since hypothyroidism can lead to sudden death post-operative. If you are diabetic, special steps must be taken to control your blood sugar. Because surgery increases cardiac stress, your heart will be thoroughly evaluated. These tests will determine if you have liver malfunction, breathing difficulties, excess fluid in the tissues, abnormalities of the salts or minerals in body fluids, or abnormal blood fat levels.

Patients who have significant gastrointestinal symptoms such as upper abdominal pain, heartburn, belching sour fluid, etc., may have underlying problems such as a hiatal hernia, gastroesophageal reflux or peptic ulcer. For example, many patients have symptoms of reflux. Up to 15% of these patients may show early changes in the lining of the esophagus, which could predispose them to cancer of the esophagus. It is important to identify these changes so a suitable surveillance or treatment program can be planned.

The sleep study detects abnormal stopping of breathing, usually associated with airway blockage when the muscles relax during sleep. This condition is associated with a high mortality rate. After surgery, you will be sedated and will receive narcotics for pain, which further depress normal breathing and reflexes. Airway blockage becomes more dangerous at this time. It is important to have a clear picture of what to expect and how to handle it.

The most common reason a psychiatric evaluation is ordered is that your insurance company may require it. Most psychiatrists will evaluate your understanding and knowledge of the risks and complications associated with weight loss surgery and your ability to follow the basic recovery plan.

Medical problems, such as serious heart or lung problems, can increase the risk of any surgery. On the other hand, if they are problems that are related to the patient’s weight, they also increase the need for surgery. Severe medical problems may not dissuade the surgeon from recommending gastric bypass surgery if it is otherwise appropriate, but those conditions will make a patient’s risk higher than average.

New evaluation appointments are usually booked 4-8 months in advance. Once a patient is seen, if the surgeon and patient agree it is appropriate, the operation can usually be scheduled within 8 weeks. When the number of patient waiting for weight loss surgery is greater than the amount of available qualified bariatric surgeons, there will be a scheduling delay.

• Select a primary care physician if you don’t already have one, and establish a relationship with him or her. Work with your physician to ensure that your routine health maintenance testing is current. For example, women may have a pap smear, and if over 40 years of age, a breast exam. And for men, this may include a prostate-specific antigen test (PSA).
• Make a list of all the diets you have tried (a diet history) and bring it to your doctor.
• Bring any pertinent medical data to your appointment with the surgeon – this would include reports of special tests (echocardiogram, sleep study, etc.) or hospital discharge summary if you have been in the hospital.
• Bring a list of your medications with dose and schedule.
• Stop smoking. Surgical patients who use tobacco products are at a higher surgical risk.

No.  Laparoscopic operations carry the same risk as the similar procedure, performed as an open operation.  The benefits of laparoscopy are usually, less discomfort, shorter hospital stay, earlier return to work, and much-reduced scarring.

The basic rules are simple and easy to follow:

• Immediately after surgery, your doctor will provide you with special dietary guidelines. You will need to follow these guidelines closely. Many surgeons begin patients with liquid diets, moving to semi-solid foods and later, sometimes weeks or months later, solid foods can be tolerated without risk to the surgical procedure performed. Allowing time for proper healing of your new stomach pouch is necessary and important.
• When able to eat solids, eat 2-3 meals per day, no more. Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources should be eaten first. These should comprise at least half the volume of the meal eaten. Foods should be cooked without fat and seasoned to taste. Avoid sauces, gravies, butter, margarine, mayonnaise and junk foods.
• Never eat between meals. Do not drink flavored beverages, even diet soda, between meals.
• Drink 2-3 quarts or more of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operation.
• Exercise aerobically every day for at least 20 minutes (one-mile brisk walk, bike riding, stair climbing, etc.). Weight/resistance exercise can be added 3-4 days per week, as instructed by your doctor.

When you have a weight loss surgery procedure, you lose weight because the amount of food energy (calories) you are able to eat is much less than your body needs to operate. It has to make up the difference by burning reserves or unused tissues. Your body will tend to burn any unused muscle before it begins to burn the fat it has saved up. If you do not exercise daily, your body will consume your unused muscle, and you will lose muscle mass and strength. Daily aerobic exercise for 20 minutes will communicate to your body that you want to use your muscles and force it to burn the fat instead.

Many patients are hesitant about exercising after surgery, but exercise is an essential component of success after surgery. Exercise actually begins on the afternoon of surgery – the patient must be out of bed and be walking. The goal is to walk further on the next day, and progressively further every day after that, including the first few weeks at home. Patients are often released from medical restrictions and encouraged to begin exercising about two weeks after surgery, limited only by the level of wound discomfort. The type of exercise is dictated by the patient’s overall condition. Some patients who have severe knee problems can’t walk well, but may be able to swim or bicycle. Many patients begin with low-stress forms of exercise and are encouraged to progress to more vigorous activity when they are able.

It is strongly recommended that women wait at least one year after the surgery before a pregnancy. Approximately one year post-operatively, your body will be fairly stable (from a weight and nutrition standpoint) and you should be able to carry a normally nourished fetus. You should consult your surgeon as you plan for pregnancy.

Contact your original surgeon – he or she is most familiar with your medical history and can make recommendations based on knowledge of your surgical procedure and body.

In some surgical procedures, the stomach is left in place with intact blood supply. In some cases, it may shrink a bit and its lining (the mucosa) may atrophy, but for the most part, it remains unchanged. The lower stomach still contributes to the function of the intestines even though it does not receive or process food – it makes intrinsic factor, necessary to absorb Vitamin B12 and contributes to hormone balance and motility of the intestines in ways that are not entirely known. In the BPD procedures, some portion of the stomach is completely removed.

This can vary by surgical procedure and surgeon. In the Roux-en-Y gastric bypass, the stomach pouch is created at one ounce or less in size (15-20cc). In the first few months, it is rather stiff due to natural surgical inflammation. About 6-12 months after surgery, the stomach pouch can expand and will become more expandable as swelling subsides. Many patients end up with a meal capacity of 3-7 ounces.

The staples used on the stomach and the intestines are very tiny in comparison to the staples you will have in your skin or staples you use in the office. Each staple is a tiny piece of stainless steel or titanium so small it is hard to see other than as a tiny bright spot. Because the metals used (titanium or stainless steel) are inert in the body, most people are not allergic to staples and they usually do not cause any problems in the long run. The staple materials are also non-magnetic, which means that they will not be affected by MRI. The staples will not set off airport metal detectors.

It’s normal not to have an appetite for the first month or two after weight loss surgery. If you are able to consume liquids reasonably well, there is a level of confidence that your appetite will increase with time.

Most pills or capsules are small enough to pass through the new stomach pouch. Initially, your doctor may suggest that medications be taken in liquid form or crushed.

Most patients have no difficulty in swallowing these pills.

Patients can return to normal sexual intimacy when wound healing and discomfort permit. Many patients experience a drop in desire for about 6 weeks.

Both men and women generally respond well to this surgery. In general, men lose weight slightly faster than women do.

Patients are encouraged to stop smoking at least one month before surgery. Smoking increases the risk of lung problems after surgery, can reduce the rate of healing, increases the rates of infection, and interferes with blood supply to the healing tissues.

Patients may begin to wonder about this early after the surgery when they are steadily losing a significant amount of weight per month, or maybe once they’ve reached their goal weight and they’re still losing weight. Two things happen to allow their weight to stabilize. First, a patient’s ongoing metabolic needs (calories burned) decrease as the body sheds excess pounds. Second, there is a natural progressive increase in calorie and nutrient intake over the months following weight loss surgery. The stomach pouch and attached small intestine learn to work together better, and there is some expansion in pouch size over a period of months. The bottom line is that, in the absence of a surgical complication, patients are very unlikely to lose weight to the point of malnutrition.

Many people heavy enough to meet the surgical criteria for weight loss surgery have stretched their skin beyond the point from which it can “snap back.” Some patients will choose to have plastic surgery to remove loose or excess skin after they have lost their excess weight. Insurance generally does not pay for this type of surgery (often seen as elective surgery). However, some do pay for certain types of surgery to remove excess skin when complications arise from these excess skin folds. Ask your surgeon about your need for a skin removal procedure.

In general, the basic rules for gastric bypass patients are as follows:

• Eat 2 -3 meals per day, no more.  Protein, in the form of lean meats (chicken, turkey, fish), and other low-fat sources, should be eaten first and should comprise at least half the volume of the meal eaten.  Foods should be cooked without fat, seasoned to taste.  Avoid sauces, gravies, butter, margarine, mayonnaise, and junk foods.
• Never eat between meals – nothing.  Do not drink flavored beverages, even diet soda, between meals.
• Drink 2 -3 quarts, or more, of water each day.  Water must be consumed slowly, 1 -2 mouthfuls at a time, due to the restrictive effect of the operation.
• Exercise aerobically every day, for 20 minutes at least (one-mile brisk walk, bike riding, stair climbing, etc.).  We encourage weight/resistance exercise 3 – 4 days per week.

When each meal is satisfying, this is not a diet, but a style which you can easily achieve, and which will result in rapid weight loss followed by weight maintenance.

Nutritional counseling will take place before and after surgery as required by Dr. Lyass. He provides patients with materials that clearly outline his expectations regarding diet and compliance with guidelines for the best outcome based on your surgical procedure. After surgery, health and weight loss are highly dependent on patient compliance with these guidelines. You must do your part by restricting high-calorie foods, by avoiding sugar, snacks, and fats, and by strictly following the guidelines set by Dr. Lyass.

Generally speaking, taking supplements after surgery is important for three reasons:

• To make sure you get adequate vitamins and minerals even though you are eating less food
• To help prevent deficiencies that you are at greater risk for because of your procedure (especially for malabsorptive procedures)
• In some cases, to treat a nutritional deficiency

The most common types of supplements taken after surgery are multivitamins, calcium, vitamin B12 and iron.

B12 injections are sometimes suggested once a month for the first year and every six months thereafter. B12 may also be taken orally or sublingually (under the tongue) by many patients. Most surgeons recommend a daily multivitamin for the rest of your life.

Dependant upon the procedure, your surgeon might recommend a liquid diet followed by semi-solid foods or pureed foods, for a period of time until adequate healing has occurred. Your surgeon will provide you with specific dietary guidelines for the best post-surgical outcome.

Most patients are able to enjoy spices after the initial 6 months following surgery.

Many patients do find carbonated beverages or sodas uncomfortable and it is recommended that you avoid any flavored drinks between meals, such as diet soda, coffee, and tea for the following reasons:

• They can cause gas and bloat. Carbonated beverages like sodas contain gas, which can cause bloating, discomfort and abdominal distension. Carbonation can also place added stress on your incision, which can interfere with the healing process. You will need to avoid carbonated drinks of all kinds for a minimum of three months after weight loss surgery.
• They can cause dumping syndrome. If you’ve had gastric bypass, eating or drinking anything with high sugar content can lead to dumping syndrome. The result is a very unpleasant feeling, as you break out in a cold clammy sweat, turn pale white, feel butterflies in your stomach and a pounding pulse. This may be followed by cramps and diarrhea. This state can last for 30 – 60 minutes, and is quite uncomfortable – most have to lie down until it goes away.
• They can slow down weight loss. Non-diet sodas and other sugary beverages are full of empty calories, which can slow down your weight loss efforts.
• They can activate your hunger mechanism.  This can lead to snacking which will slow down your weight loss and can lead to regaining of weight.

Milk contains a special sugar, called lactose, or milk sugar, which is not well digested. This sugar passes through undigested, until bacteria in the lower bowel act on it, producing irritating byproducts, as well as gas. Depending on individual tolerance, some persons find even the smallest amount of milk or milk sugar will cause cramps, gas, and diarrhea.

Solid foods such as red meats contain a high level of meat fibers (gristle) which hold the piece of meat together, preventing you from separating it into small parts when you chew. The gristle can plug the outlet of your stomach pouch and prevent anything from passing through, a condition that is very uncomfortable.

After about eight weeks (on the gastric bypass diet), you can gradually return to eating firmer foods. But foods must still be chopped or diced. Start slowly with regular foods to see what foods you can tolerate. You may find that you still have difficulty eating spicier foods or foods with crunchy textures.

Other foods you should avoid because they may cause gastrointestinal symptoms, such as nausea, pain or vomiting:

• fried foods
• nuts and seeds
• bread
• popcorn
• dried fruits
• carbonated beverages
• granola
• stringy or fibrous vegetables, such as broccoli, celery, cabbage or corn

Over time, you may be able to try some of these foods again, with the guidance of your doctor.

When you are losing weight, there is a heavy load of waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you and helps your body to rid itself of waste products efficiently, promoting better weight loss.

Water will also fill your stomach and will help to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it is because you did not drink enough water in the hour before.

You will find that even small amounts of alcohol will affect you quickly and most alcohol is considered liquid calories which contradicts the purpose of undergoing weight loss surgery in the first place. It is suggested that you drink no alcohol for the first year. Thereafter, with your physician’s approval, you may have a glass of wine or a small cocktail. It is important to note that according to research published in 2017 in an online issue of the journal of the American Society for Metabolic and Bariatric Surgery (ASMBS) that weight loss surgery increases the risk of alcohol use disorder (AUD) and that alcohol abuse can happen even years after surgery.  Given the research, people who’ve had bypass surgery might want to stay away from alcohol altogether.