GeezerSue

Sandy is an Ortiz patient and promotes his services in various arenas. In other words, it is yet another advertising campaign.

It IS a long way to Monterrey every time you need to see your surgeon.

Roberto Rumbaut Diaz of Monterrey, MX, was my surgeon as well. Dr. Rumbaut is from a Cuban family, attended junior high in Ohio (so hs English is better than mine) and then he completed his education in Mexico, as his family relocated there after his junior high school years. He is one of the very few doctors (I think there were five or six) who participated in the pre-FDA testing. That is, before the FDA allowed the trials to be conducted here, they had to look at results from elsewhere. They looked at Rumbaut's results. And, he is one of even fewer band surgeons who is also a band patient. He often does about five band placements per day, two days per week. when I got mine almost two years ago, he had placed over 1400. Now it's over 2000. (some doctors will say, "WE'VE PLACED X-bands...", and then they add up all the bands placed by all the doctors in the practice. Rumbaut counts the ones HE has done. The hospital is a teaching hospital; you'll have a private room with a bed or sofa for a family member and a private shower. There are about four or five patients per nurse, post-op. Patients stay at the Hampton Inn, next door to a McDonald's an Applebee's and a shopping center. Applebee's provides limited room service at the hotel. Patients are taken from appointment to appointment by the hospital's van or by taxi, included in the room rate. He get about a billion emails a day, so he is NOT the fastest at answering them. But he gives you HIS cell phone, not an assistant's. And he has even answered a call from me while he was on a stage in Chicago getting ready to give a lecture. (I asked if I should call back later, he said, "No, it's not my turn to talk yet.") If you call his office, he returns calls promptly. Feel free to ask more specific questions if you have them. BTW, he is a proctor for US doctors. That's what he was doing on the stage in Chicago and his band surgeon was Franco Favretti in Italy. Sue

Me, too. And it's easier than making up your own BS...

oops

BTW, the goal of the letter was to say, "Kindly find someone else to F*** with, because I don't plan to make this easy for you."

Just so you can see what we wrote. I don't think this was our FINAL appeal letter--there may be a later version--but it was the ONLY one. ~~~~~~~~~~ Name Address Los Angeles, CA 90036 Phone 14 April 2003 Chris Jagmin, M.D., Medical Director Patient Management Department Aetna Insurance Company 2777 Stemmons Freeway Suite 300 Dallas, TX 75207 Re: Your denial letter dated: xxxx Member Name: xxxx Date of Birth: xxxx Reference #: xxxx Employer Name: xxxx Employer Account Number: xxxx Dear Dr. Jagmin, I am in receipt of your denial letter dated xxxxxxxxx and submit the following information in support of this appeal for reconsideration: It is my understanding that I do meet Aetna’s criteria for coverage of breast reduction surgery because my surgery will be performed for reconstructive indications, I am over age 18, and I have met the following criteria, as documented by my physician and chiropractor: A. I have a diagnosis of Macromastia, and 1. I have persistent symptoms in the following five (5) anatomical body areas below, affecting daily activities for at least five years: * Pain in upper back * Pain in neck `* Pain in shoulders * Headaches * Pain / discomfort / ulceration from bra straps cutting into shoulders; AND 2. ALL of the following criteria have been met: a. Photographic documentation confirms severe breast hypertrophy; and b. My PCP has documented that chronic pain symptoms are caused by macromastia; and c. I have undergone an evaluation by my PCP who has determined that ALL of the following criteria are met: i. The pain cannot be solely explained by a musculoskeletal condition (e.g., arthritis, spondylitis, acromioclavicular strain); and ii. Reduction mammoplasty is likely to result in improvement of the chronic pain; and iii. Pain symptoms persist as documented by the PCP despite years of therapeutic measures such as: * Supportive devices (e.g., proper bra support, wide bra straps) * Analgesic / NSAIDs interventions * Physical therapy / exercises / posturing maneuvers Remaining, then, is the issue of the quantity, in grams, of breast tissue, not fatty tissue, which will be removed from each breast, based on my body surface area (BSA). Your chart indicates that the amount of tissue you require be removed is 1055.7 grams per breast, while the peer reviewed literature you cited (1. Miller, et al.) argues that the quantity of tissue removed did not correlate with outcome in the mammaplasties studied. Five board-certified plastic surgeons have now examined me and agree that a substantial amount of tissue needs to be removed from each breast for non-cosmetic reasons. The weight of the tissue those five surgeons have proposed removing ranges from a low of 450 grams to a high of 1050 grams, even though each surgeon proposed leaving the same amount of breast tissue. The surgeon who proposed the 450 gram reduction is the one whose preauthorization you have rejected. Since that request was submitted, I have elected to utilize the services of a different physician, a board-certified plastic surgeon within Aetna’s network of providers, who--like the other four surgeons and the current literature (2. Bruhlmann Y, et al.)--recommended a reconstructive removal of less than the 1055.7 grams on your chart. While the use of BSA as a general guide seems reasonable, complete reliance on that criteria would suggest that Aetna does not consider bone structure, muscle mass or other specifics regarding the individual. All of those factors--and others--were taken into consideration by the five board certified plastic surgeons who examined me, prior to their stating that such surgery is indeed medically necessary in my specific case. Attached please find statements from my PCP and Chiropractor. I look forward to a positive response to this appeal. Meanwhile, xxxxxxxx, M. D. will be submitting a request for coverage verification and authorization for this surgery. Sincerely, xxxxxxxxxxxx Enclosures: 2 xxxxxxx, M.D. xxxxxxx, D.C. References: 1. Miller AP, Zacher JB, Berggren RB, et al. Breast reduction for symptomatic macromastia. Can objective predictors for operative success be identified? Plastic Reconstruct Surg. 1995;95(1):77-83 2. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Ann Plast Surg 1998 Sep; 41(3):240-5 ~~~~~~~~~~ Pretty good if I say so myself!

First step...call Don Mills at Inamed and ask if he has had any success with fighting the BC "experimental" thing. Sometimes, they have had the surgeons explain whay the patient is NOT a good candidate for the bypass and they get through that way. Anybody got Don's number close by? Other first step...find out if your employer is a self-pay for insurance. If so, they are actually the ones making the decisions and BC is just administering the plan. If not, they are covered by the CA state insurance commissioner (they have a web site.) They have a three times and then to outside review thing. One thing I found handy when I was on the phone pretending I was my daughter (her job at the time did not allow for personal business calls) fighting for her breast reduction with Aetna...dumb-sounding-questions-with-a-plan seem to get their attention. As in, "Okay, so does this count as the first time you've turned me down? So then, does this go to outside appeal after the second time and the third time is the outside appeal or do you have to actually turn me down three times before we go there...I'm sorry, but this is new to me and I want to make sure I understand it all." And ask everyone how to spell their name, and explain that's it's nothing personal but you know it's probably going to end up going for outside review and you at least want to spell the names correctly. Be loving and kind and their new best friend. Also, I did end up using Aetna's journal citations for our kid's appeal. If I could find a contrary opinion in the abstract, I quoted it, just like they did. if I could find a later publication by the same researcher which contradicted the first citation, I quoted it. They never DID turn her down the second time, because they knew that she was ready to go the whole way and that they would lose. Go for it. Sue

According to the Blue Cross CA website, they consider the band experimental. Which is bunk. And they use antique literature to back up that claim. (Additionally, some policies may not allow for ANY weight loss surgery.) You should contact Don Mills at Inamed and ask him if he has had any successful reversals of that policy. http://medpolicy.bluecrossca.com/policies/surgery/morbid_obesity.html

My friend just named her last animal "Hamburger" and that kind of kept it in perspective for her.

Newlapper, How much you can drink and how much you can eat of things that melt at body temperature (almost) cannot be impacted by tightening the band. For many of us, there is almost no limit to how much we can drink and how much of stuff that melts we can eat. The band only works on solid food; the rest (much to our dismay) is all about headwork. Many of us cannot eat even a tiny bit of potato, but we can eat a bag of potato chips. Can't eat an egg, but can eat the entire box of meringue Cookies. Can't eat two pieces of boiled noodle, but can eat a bag of fried noodles. Can't eat an orange segment, but can drink orange juice or a box of frozen orange fruit bars. I speak from experience here....this is NOT about restriction, this is the head part. What getting overtightened does is teach you how to eat all the wrong stuff, since the tighter you are, the less good stuff you can eat. So if you can eat a half a chicken, you probably need a tighter fill. But if you can drink a six pack of soda, I think we all can. If you can eat a banana, you MIGHT need a fill. But if you can eat the entire banana split EXCEPT for the banana, join the club. And if you can eat a handful of rasins you MAY need a fill, but if you can eat a RitterSport chocolate bar except for the raisins, so can most of us. Now, here's where it gets sticky...if you have the right fill but just need to do some headwork and get a tighter fill instead, then you will ONLY be able to drink the soda and eat the banana split except for the banana, and THAT'S when you start to gain weight. For headwork, talk to Donali. She's the smart one. Sue

oops

No, not criticizing YOU, New. But I would criticize a doctor who would tighten up a band that is doing so well. Some will...just to shut the patients up. But REALLY, you are doing PERFECT. I think any of us would want to be doing exactly what you are. Thanks, NewHope. Sue

Welcome, B... There are lots of So. Cal. folks on the board. And all levels of experience from pre-banded to the formerly banded (she's a wild one). Look around and enjoy. Sue

But just a comment...you asked for input and I gave you mine. I've been banded for almost two years, been reading about it for three, often in medical journals, have spoken/corresponded with a half-dozen surgeons, have suffered from and seen others suffer from GERD (which can kill you) and erosion (which can slice through your stomach/esophagus) and my comment/suggestion is to leave well enough alone. I don't know how much weight you need to lose, but, at this rate, in a year you will weigh 138 pounds less than you did pre-op. Good luck!

Again...unless you have studied what all the numbers mean and understand them, forget the numbers. If your doctor puts 4cc of saline in your just band because you've decided that a 4cc band should have 4cc's in it, he should lose his license...and you'll probably lose part of your esophagus. I'm thinking that someone did not prepare you for this surgery. This is the band, not the bypass. In an IDEAL case, you'll lose about 10 pounds per month. Having the band too tight does NOT mean you'll lose more weight or lose it faster. In fact, it can mean that you will start "eating around the band" and STOP losing weight. The band is not about losing weight overnight...it's about how healthy you'll be in two years or five. THIS IS NOT A DIET. And it's not a race. It's about the rest of your life. Slow down, take a deep breath and read all you can about the band. you do NOT want it so tight that you starve this week, because next week they'll be taking it out and you'll be back to where you were pre-op. We have all been where you are...but remember that FAST does not equal GOOD. Sue

Newlapper, Forget the numbers. You have the right amount of restriction, or too much or too little. If you've lost 10 pounds per month, you probably have enough (unless you have too much restriction.) Why are you saying you can eat too much?

You are now OFFICIALLY weird. Which is way better than"rumored to be weird," right?

No. But remember that I am still obese and nowhere near goal. Maybe when I lose another 80 pounds (I'd settle for 60, honest I would) it will be in the way. I'm thinking that I may have to do something to actually lose weight. Like exercise or eat reasonably, that kind of thing. I not yet committed to that concept, but I'm working on it. And I have no fill and probably won't until September or so. (I've got a consult and from that we may have an endoscopy, just for the hell of it, so I'm not going to mess with the band until then.)

As far as I know, Rumbaut almost always uses a sternum placement (kinda between the breasts). He's my surgeon; that's where mine is; that's where everybody who was banded the day I was has their port. that may even be where HIS port is located...I didn't ask.

I may sound a tad schizophrenic here, but I'll try anyway. It's important to be able to have follow-up care that you can get to easily, especially in an emergency. But, i would cross many county lines for a doctor with experience. I'm too lazy to look up NJ county lines, but...if there's a doctor many counties away who has done 300 bands and one down the street who has done 30...I'm going to be needing the car. The complication rate decreases exponentially as the doctor's experience with the lap-band increases.

Like I said, Jane, good luck no matter how you do it. (I'm too old to even consider flying for hours with an entourage every time I need an adjustment. Funny how values change as we get more and more worn out.) Y que muchahos tan bonitos...y que esposo tan guapo. Sue

The hotel is fine if you don't mind ROCK HARD mattresses. There is a coffee shop kind of restaurant with buffets and menu service as well as a very nice formal restaurant on the property. There is an unheated (I think) swimming pool. A couple of blocks up the street, here's an IMAX theater and an art museum as well as a kiddie-park entertainment place, but, as you know, their safety standards are not the same as ours. A little farther north, a few more blocks, there's a major shopping center. BTW, since you have your after care under control, are you aware that Sanchez and Rumbaut in Monterrey, MX are way closer to you and I think they have done more bands than any other doctors on the continent? (They do not work together.) The transportation would be easier, Rumbaut's patients stay at a Hampton Inn next door to a McDonald's, an Applebee's and a shopping center--and that hotel has a pool as well. Rumbaut uses a teaching hospital. Sanchez uses a hospital that includes a floor with hotel rooms for the patient and family for the post-op stay. Ortiz is competent, to be sure, but the logistics of getting there are not good. Monterrey would be not quite as bad. But the best is an experienced doctor you can get to if you really need him. (I've needed nine adjustments, aka fills, in less than two years; DeLarla just did a speed drive through two states and across the border with a port working its way out of her body...that kind of stuff.) Given your logistical considerations (I mean the need to bring the kids with you), are you sure you've examined US doctors who are closer and fairly reasonably priced? Good luck wherever you go, Sue

You have some VERY experienced surgeons in Australia...and in NZ. Did you know there are also (because we don't want you to leave here) Yahoo groups for the "down under" banded? Anyway, MY first criteria is/was "the more bands the better." I went FAR away to find a surgeon who had done over 1400. Next was the kind of facility. But not everybody agrees.

So, Megan... i bought some JNJ stock when those trials started. Am I a smart girl or a dummy? Sue