So today was important. But not for reasons that I had anticipated.

I was told I needed letters of medical necessity from every physician that treats me. For me that means my PCP and my OB/GYN. I got the letter from my PCP last month. But the earliest I could get into see my OB/GYN was today. He agreed to give me the letter.

I had that appt right at 8 am and then headed into the medical center to my second weightloss appt and my nutrition consult.

So I had it backwards in my head about which appt came first. I thought the nutrition consult was second. So this person comes in and doesn't identify herself as "the nutritionist", just gives me her name and asks if I had any questions. So I asked her all my general questions about my insurance predicament.

Man. I didn't really KNOW what that predicament was. Cause it's a whole lotta different than I thought it was. There's a new one...and it's the real one...

She didn't know, told me I'd have to talk to my advocate who was not there today. Said call her Monday.

So we have some general conversation about my diet over the last month. I told her about my cleaning out of the pantry and my moves towards the "good stuff". I really am eating the good stuff with just little snippets of the bad stuff here and there - mostly on weekends. Most of what is in my pantry will be ok to restock in the future if I so desired. Still a few clean out things - but she wasn't into that whole "just throw it all out" notion. She was more into "be aware" - which I think I am and she claimed to think I was at the end of the appt, too. But in the last half hour with her I realized - she's the nutritionist and then in the last twenty minutes she got on her little soap box and the judging began.

Oh well. I do hate that - but I have never met a nutritionist that CAN'T judge...

Ok. So no real problems so far.

The Nurse Practitioner eventually wanders in after the nutrition consult was over and she listens to my heart and lungs and says good job and is ready to send me on my merry way.

Hold on...I think to myself.

Since I now know I was talking to the nutritionist I'm thinking some of my "vague" questions might be answerable by the RNP. And two of them were. Yay!

Somewhere along the line in the conversation with the nutritionist I think to myself - why can't I see one of the advocates that IS here. It doesn't have to be anything specific to my case, it doesn't mean anyone is looking up my specifics. I just had some general questions.

And the RNP suggested that I do that...talk to one of the advocates that WAS there.

So they go tell the advocate that was still there at the lunch hour that I have some questions and she comes and gets me after a bit.

And I tell her my story.

My company is changing my insurance options pretty drastically and I'll be left with a hefty deductible and a hefty OOP-Max (Out Of Pocket) or I'll be left with a ginormous deductible and a ginormous OOP-Max. The one with the ginormous options comes with a HSA, though - a health savings account. It's kinda like a health spending account but money left in the savings account at the end of the year will not be forfeited. And my employer will treat it like a 401K and will be putting money in that account for me as well as my own contributions. That account is (according to my employer) designed to pay for my healthcare after I retire. A third option is to switch to my husbands plans. He is currently on mine but we can walk away from mine and he would go back to his and I'd start up on his. If we did that, we could get a plan that is fairly comparable to my current plan - and the surgery would be paid for. Premiums are a bit higher than my two options - but they are actually $16 less than what we are currently paying. My insurance provider is Cigna. My husband's through his employer is Aetna.

I know I have the Cigna requirements for eligibility that I was given last month covered.

• A BMI over 40
  
• a nutrition consult
  
• a pysch eval
  
• a 6 month supervised weightloss program
  
• letters of medical necessity from all treating physicians.
  

On the other hand, Aetna's requirements for my husbands optional plans are:

• A BMI over 40
  
• a nutrition consult
  
• a pysch eval
  
• a 3 month supervised weightloss program
  
• letters of medical necessity from my PCP
  
• and a 2 year history of obesity
  

So my question going in was is obesity a BMI over 40? Or is over 35 sufficient since I am NOW over 40?

Yep, gotta have a minimum of 40 for all two years or more.

I have no comorbidities. I don't want any. My dad died from type II diabetes and heart disease and my mom died from colon cancer. I have PLENTY of risks already - I don't need to add the weight, dagnabit!!!!

I love that word!

And then this advocate lady says - Aetna is the same as what you need for Cigna, so I'd recommend switching.

No. I have this form RIGHT here that THIS office gave me that says my requirements are:

• A BMI over 40
  
• a nutrition consult
  
• a pysch eval
  
• a 6 month supervised weightloss program
  
• letters of medical necessity from all treating physicians
  

And she says, no, for your group on Cigna you need:

• A BMI over 40
  
• a nutrition consult
  
• a pysch eval
  
• a 6 month supervised weightloss program
  
• letters of medical necessity from my PCP
  
• and a 2 year history of obesity
  

And follows that with - what piece of paper do you have? So I pull it out of my handy dandy little folder and hand it to her.

And she reads the top line. And she says - you shouldn't have this form, this isn't YOUR group.

So I'm not eligible.

Now.

After doing the pysch consult. The nutrition consult. After redoing the stress test and my cardiologist I never saw in the first place signing off on it. After having my PCP and my OB/GYN agree to it. After ALL of that - and 4-8 missed hours of work EACH week since I started down this path - I find out I AM NOT ELIGIBLE

:drool::ohmy::drool::drool::drool::drool:

So she starts digging further. How did I get given this misinformation? Turns out THIS lady IS my advocate. Who knows why the other lady's name is written all over my chart - the one I am talking to is the one that has handled everything for my case so far.

And now it makes sense.

See. The problem is that I have not even been at this weight for a year let alone two.

And my advocate breaks it down like this. If I do Aetna, I will be done with the weightloss program in early Jan. They submit my package, I get my approval, surgery in Feb. OK. Since they submit the package in Jan, Aetna will want two years which means going back to Jan of 2008.

Jan 2008 = 132 pounds. For me that's a BMI of 37.4

Jan 2009 = 138 pounds. For me that's a BMI of 38.4.

It was in March/April of this year that my weight went crazy putting me over the BMI of 40.

I gain weight when I get OFF of birth control. I have gotten off of birth control four times and four times I have had the same reaction - 30-40 pounds before my hormones are back to normal and then I can hold steady from there.

It is generally fairly easy for me to maintain a weight. It is literally when I play with my hormones that I get in trouble. With that said, sometimes my hormones play with themselves - and I know as I get older they will do that even more. And those times are just as damaging for my weight control.

So that part that "makes sense".

In October I went into my surgeon's office. And the RNP there told me that I would qualify if I proved two comorbidities along with my BMI of 40.

And to prove those comorbidities I would need to go to this other clinic in the medical center where I would also do my six month supervised weight loss program.

I have high cholesterol. She told me that would be one comorbidity and probably doing a sleep study would prove the second one. So I should be good.

But I get to this other clinic a few days later and they say - no, you don't need any comorbidities.

So this advocate - still scared to call her mine cause am I gonna end up with someone else later? - says well then lets get a sleep study.

Are you drowsy in the afternoon? No.

Do you wake up with headaches? No.

Do you snore? My husband says No.

Hmmm...then I won't qualify as needing a sleep study.

And then she says - get this - well, you could do some things to prove type 2 diabetes?

Excuse me?

Excuse me?

Excuse me?

Excuse me?

The disease that KILLED my dad - you want me to "play around with that"? Really?

My blood pressure is absurdly LOW. Got any tricks for screwing that up?

My heart has been deamed healthy by none other than a cardiologist.

So she goes and gets the RNP eventually.

Apparently you can be determined as qualified for a sleep study if 1) your neck is too big, 2) your waist is too big, and 3) if you say you are sleepy during the day.

1) my neck is huge. :ohmy: I call it a football neck.

It works on my body, I have a very strong neck and if we have boys when my husband and I have kids - they will have a good build for being football players. I like my neck. I will be happy when it loses weight, but I don't have an issue with my "huge" neck.

2) my waist is large. I'm fat. That was easy.

3) sure - I can say I'm sleepy. I sit at a computer all day long and around mid afternoon I get bored. And when I get bored, I get sleepy.

Its so different here in Aussie..... I got a referral from G.p picked surgeon, had a consult and booked sugery. Health fund paid. Maybe you should just move?????? Now see surgeon every 4 weeks , support group 1 x month, and nutritionist if I feel I need too. Lost 30 kgs. Had band 28 may 09

Cheers Chooky