Alexandra

People: Whatever our reactions may be to the initial post, please remember this is a support board and attacking people is NOT permitted. If you have nothing to say that is constructive, say nothing. Or keep it circumspect, at least. This thread will be locked if personal attacks continue. Jodie, you've gotten some good advice here even so. Please take care of yourself first; everything else comes second.

That is really odd, Karen. The problem is, why would an out-of-network doctor even be willing to send anything to your insurer for preapproval? He's not a participating doc, which means he doesn't have to do ANYTHING they say if he doesn't want to. His relationship with, and responsibility is to, his patient, not his patient's insurance carrier. I think this puts the patient in a very awkward and untenable position. I mean, sure, most doctors would want to be helpful but there are loads who don't participate with any insurers specifically because they don't want to play the paperwork/permission game. So if someone is going to one of those types and Oxford says it wants documentation prior to the service, the patient is going to be in big trouble. I would have thought the patient would go ahead with the surgery, then collect all the information and bills and submit after the fact for a coverage determination. If they agree, payment would go directly to the patient. Certainly Oxford has the right to apply its same criteria for medical necessity when it is considering the claim, but to require pre-authorization doesn't seem right. You've got me wondering, now. I'm also an Oxford member as well as an insurance broker, so it's important for me to really understand these things. If I have a few minutes today I think I'll call them and see what answer I get to the same question.

The removal procedure was a walk in the park, actually. I was on the OR table at about 4:00 p.m. and home the same evening at, um, 8:00? The next morning I felt great, and I could have gone to work that afternoon (but didn't). There was no need to take the next day off either, but I did anyway. Really, I felt wonderful and was amazed!

As I understand it, family leave can be requested for any purpose involving medical care, one's own or that of a family member. I have a sneaking suspicion that asking your husband ti disclose that information is in violation of HIPAA law, too. But (if I may ask) why is he requesting FMLA leave? How much time is he expecting to take off?

Awwwww.....

Congratulations, Lauren! Do they live close to you, and will you be able to see the child often? I hardly know my niece and nephew because they live on the Left Coast. Have fun!

This method by no means automatically means you'll be overfilled, not at all. It is just another way of approaching the actual mechanics of a fill. Closing it off entirely for a moment can be very instructive; that way the patient gets and idea what too tight feels like, so she can recognize it if it happens again. Once the doctor pulls out Fluid there is nothing different than if he'd never done the tightening thing at all. It's only for a moment, and (at least in my doc's case) watching the fluoro is really the way he's judging the final restriction, not by the amount of fluid he's put in or taken out.

This is essentially the way my surgeon's office does it. Dr. Bertha does it under fluoroscopy and will fill the band tightly to close it off completely, so that the patient gets to feel what this is like. Then he'll back off a bit, and a bit more, watching the fluoroscope as the patient drinks barium so he can see when he's reached the right level of restriction.

Actually, it does make sense. All those tests are to determine IF you are medically qualified for surgery. The request for precert wouldn't be complete without them, and the carrier wouldn't even look at it. But with a BMI of 52 it's unconscionable that your carrier would say you are not medically qualified. That is a very strong ground for appeal. If you had insurance prior to May 1, you would not be subject to that pre-existing condition exclusion. You just have to show that you had prior coverage.

Karen, by definition approval is not needed for an out-of-network provider. The surgery must still be considered medically necessary, in order to be reimbursable, but you will submit the claim after the fact and the payment will go to you. You should call Oxford to determine what precertification might be necessary for the surgery itself, but as long as you realize that the deductible and coinsurance are your responsibility then using out of network providers doesn't need approval from Oxford.

Wheetsin, as usual, beat me to it. 396, how does "abortion used to be against the law" equate to "we used to have no abortion"? They are very much NOT the same thing.

I'm not sure where you're putting yourself on the scale, because the questions on your list seem like those that higher BMI folks would direct toward lower BMI folks. So I'm a little confused. But that said, all that matters is that we ALL realize and recognize that the battle against excess weight is a personal one. I've been morbidly obese for at least 20 years, but it wasn't until I had children that I realized I was not only compromising my health (which seemed OK, on balance, to me) but their safety. I'm sure that for all of those 20 years many other people no doubt snickered at me and thought less of me, but those were not people I bothered with. I remember one particular guy I worked with who came out and said something like "you're a big girl, aren't ya?" directly to my face with other people watching, and I just wrote him off immediately. He was beneath my notice and worthy only of contempt. As long as all I had to deal with was myself, I could pretend my obesity was only an inconvenience. At that time, the best way any medical person could treat me was to show respect and ignore the weight issue until I brought it up. My ob/gyn was brilliant in that regard. Though I showed up at my first prenatal appointment weighing 320 lbs she never once lectured me or talked down. I was high risk, sure, but that was handled in a businesslike manner that allowed me my dignity. No assumptions were made. Only when losing weight became my goal did my weight become a primary topic of conversation. And that was at MY instigation. I love my medical providers because they treat me as a person first, a fat patient second. Anyway, my point is that none of these thoughts/feelings have anything to do with whether my BMI was 32 or 48. My focus changed from one point in my life to another, and I think that's much more important than any conclusions one can draw from a BMI. My advice to medical providers: Let your patient lead the discussion, don't make any assumptions, and you can never go wrong.

I would have been able to "drive over to my office and work a little" two days after surgery. If you can quit or rest when you need to, you can go whenever you feel up to it. You might very well have the energy a day or two out, but what surprises a lot of people is how quickly that energy can fade during early recovery. It definitely takes a few days for energy and full movement to return for the whole day.

If the only criterion you DON'T meet is the lack of a co-morbidity, you may have grounds for an appeal even if you're denied the first time. You didn't say what your BMI is, but if it's over 40 the medical guidelines say you don't need a co-morbidity for bariatric surgery to be deemed medically necessary. If your carrier follows generally accepted medical practices and procedures, or those of the American Medical Association (check the fine print in your contract), they can't just arbitrarily decide that their medical criteria can be different from those used by the rest of the medical community. If insurance coverage is really important to you and your BMI is above 40, I'd say definitely go through the steps for precertifying. If bariatric surgery is not excluded entirely, then the case rises and falls on whether the treatment is medically necessary for you. No carrier wants to be sued for denying necessary treatment, so you will have an excellent case for appeal. If, on the other hand, your BMI is between 35 and 40, your carrier is simply sticking to the letter of the guidelines used by doctors nationwide, and they are within their rights to say no. But the surgeons I know say that it's virtually impossible for someone that much overweight NOT to have a comorbidity--it just has to be found. Is your PCP willing to help you with this? You might need additional testing, etc. It can take patience and persistence, but not only might you win yourself, you will also be making it that much easier for the next person. You will never know unless you try. Good luck!!

That's exactly what my band allowed me to do, constantly and effortlessly. Without it, this is not a thought that occurs to me. Not in time, anyway. :rolleyes

I'm another reformed smoker, though unlike many I didn't find it difficult to quit. Somehow, back in 1987 after seriously smoking for 10+ years, I just put it down. I picked it up again several years later due to a new batch of bad-influence friends but really didn't like it, so after a few butts I just said no, permanently. So that may color my opinion, but I do NOT defend anyone's right to smoke where other people might smell it. It's obtrusive and repulsive, inconsiderate and dangerous. IF the other people are given a chance to absent themselves without compromising their ability to do their jobs or enjoy a service offered to the public, then there's no reason smoking establishments can't exist. But it is time to end the circumstances that mean the general public will be subjected to toxic cigarette smoke without its consent. Local bans don't work, unfortunately, because people can easily take their business elsewhere and the merchant community has a legitimate cause for objection. But statewide bans have worked brilliantly well, and I'm looking forward to the day that they become the norm rather than the exception.

Good luck with your procedures, Karen! Evcase, best of luck to you with your insurance discussions. It's nailbiting, isn't it? Though I'm thrilled with what my doctor told me I still won't really believe it until I get the letter. Tomorrow I call the surgeon's office to see about scheduling the replacement surgery. Fingers crossed!!

Please tell me when, where, EVER, has there been "no" abortion? Never in the history of humankind has there been an absence of women doing whatever they must to end unwanted pregnancies.

I don't want to take over the thread with a rules and regs discussion, but I will say this: 396, there is a difference between saying that (for example) "knitting is boring" and saying that "knittERS are boring." That's the difference we ask everyone here to observe. The first is criticizing the activity, the second criticizes the people who do it. For all of your disapproving language, your earlier post is criticizing liberalism, not liberals. And that's the way it should be.

Hi Karen, I'm sorry to hear you'll be losing your band, but SO glad to hear you have other options! Your health and quality of life are what comes first, and you need to take care of yourself. That's especially hard when family is sick, as I'm sure you know. Good luck with everything and best wishes for strong health and healing for both you and your husband!

Hi Crabby, welcome to LBT!! Yep. the pre-op testing can be a drag, but it's all in order to make you the best you can be before undergoing this life-changing process. You're getting a tune-up!

I completely agree with Mariecarmen, but I'd go even a little farther and change the last line to "choose to find a different way to use it." YOU are the one determining your goals, so YOU are the one who will determine how best to use the lowered capacity the band gives you. The person in the OP who lost 160 lbs in 10 months obviously chose to go the ascetic route and lost WAY faster than most bandsters. That speed is RNY territory (are you sure she didn't have an RNY?). As far as plastic surgery goes, there are no guarantees. Much depends on your age, genetics, speed of loss, patience, and dumb luck. Losing weight at a sane rate, keeping well hydrated and getting lots of exercise will give you the best shot at minimizing the appearance of loose skin. But in the end, it's your choice. If you don't want to have PS, don't! It's that simple.

Who? :Banane43: :thumbs_up: Nope, 396, there was nothing even remotely inappropriate about your last post. Now, compare it to the earlier ones which we did take issue with, and you will see "attack the idea, not the person" at work.

Phyllis, I'm right now in crossed-fingers maintenance mode, trying not to gain weight before I can be re-banded in a month or so. I don't have any pipe dreams that a new band will help me lose the 50 lbs I have on me that the medical community would call "excess weight" but I am hopeful it will make the lifelong task of maintaining my weight a bit easier. Constantly clenched jaws do not make for a sensible approach to dieting. Only you can decide if therapy can help. Personally, I've never partaken professionally but I've done a lot of soul searching. What I find hardest is taking the certain knowledge that: a) I am not hungry, and :Banane43: this next bite is unnecessary and possibly harmful , and adding them up into c) I WILL NOT PUT IT INTO MY MOUTH. I'm trying to break down the disconnect between A/B and C so that I can create a connection that will stick with me. WHY is it so hard to remember NOT to eat something? My brain simply doesn't seem to access the control button until AFTER the extra calories have gone into my mouth. Am I distracted? Self-destructive? Unconscious? Stupid? In denial? What??? I don't really think I'm an emotional eater, except on the rare occasions when I consciously know that I feel [insert emotion here] and want [insert activity here] to counteract the emotion. For me that activity is just as likely to be shopping or calling a friend as it is eating, though, so it's not a major source of my excess intake. When I do get a grip of the thought process going on, I have found that there is a sense of entitlement at work--like "I can have this, I'm an adult, no one can tell me I can't..." Rationally I know I need to have another conversation with myself about the UP side of not eating something I COULD eat. The self-talk about entitlement is working at cross-purposes with my goal to improve my health, and I am the loser. That's an ongoing challenge for me, day after day after day. And I look forward to having a band at my side to help with that challenge by giving me other reasons to put the food down.

Hi Debbydo, welcome back! I'm going to be jumping back on that wagon with you very shortly. :biggrin1: Save room for me!!