DebDUtah

How many ups and downs are there on this "ride" put on by our insurance companies? I knew there were going to be hoops to jump thru, but how was I to know the hoops would change along the way!!! Let's see here is how my journey began, almost 6 months ago.... First met with my primary care doc, who once again said I might want to "think" about losing weight. Really, he said this like I have no idea that I am overweight, no wait obese, morbidly obese and he is introducing a new idea to me. I have (like everyone here) attempted, succeeded and regained, failed and basically had no success. But in a way he had, I had been looking into wls for several months and I came to the decision before ever entering his office that day that I was going to have to have wls to stay healthy. This "come to jesus" meeting about my weight was in the beginning of February. My insurance told me that I needed to have three visits no more than 2 months apart for the "supervised" diet to be considered supervised. So I planned my next visit in April, well within 2 months. Then I am told that no I have to see the dr monthly for six months, this came from my surgeon, I called the insurance company and confirmed no not every month only three months. So I continue and now I am told by my insurance that it is 3 visits in 6 months no more than 4 months apart. Oh for the love of it all.....if I didn't have a grasp on the requirements I would go insane and never meet their requirements. But I took a deep breath called again and cleared up the visit requirements a final time, and then started talking money. This opened another can of worms as I have a maximum out of pocket of 1500.00 per year and this surgery will well exceed that (hospital stay alone) so the surgeon, anesthesiologist, etc will be paid 100%. Well my surgeon was wanting $900 before he would do the surgery and the hospital was wanting 1500.00 and the gas man wanted 500.00. What part of MAXIMUM OUT OF POCKET do these people not get. I have the money to pay but I will not be worried about getting refunds on top of my recovery diet and exercise. I found out that if I pay the hospital on the day of admission they will give me a 25% discount on my portion/responsibility!! Well of course, I will pay so this left the surgeon....hmmmm how do I explain this to them. I told them why I was going to pay the hospital instead of him, his office was very understanding, I was surprised it was easy, I mean really easy they agreed that I would not owe them the 900! The first thing that went my way, yeehaw. I actually did the happy dance. So come July 9, my paperwork will be submitted I will be waiting on the utilization review department to give the thumbs up, waiting on the beginning of the rest of my life. Let's hope it is the first week of August

Are you getting any protein with your fluids, that may be the problem.

Ok hear me out on this may seem far fetched but it is doable. I have been in the health field for over 10 years, so I know how the system works. The one cost you will have out of pocket at first will be your surgeon, which can be anywhere from 3k-5k, depending on your surgeon. The surgeon will want his money up front first (normally). However, the hospital and anethesiologist will probably take payments or offer a payment plan. Call the hospital and speak with financial counseling at the hospital and see what they offer. This way you can have the surgery stateside if you don't want to go elsewhere. It is worth a shot.

For goodness sakes call your physician or if nothing else go to the ER.....this is not something to take lightly.

That is a question you need to ask your physician.

So here it is only one more visit and my supervised diet will be over, all my lab work and required doctors appointments and tests have been completed. I have to say I have not tried to lose weight during this supervised time (although I have lost a few pounds), but I have not gone wild either with food funerals as I have read others have. I have been swimming, walking and drinking lots of water to get used to it, but I am not dropping weight. I know that it is no surprise to me that I have not lost, but now I am worried that my insurance will deny me. Now I know that they cannot deny me based on my performance during this six month supervised diet, but they could deny me due to medical necessity. Ok this "medical necessity" scares me, as I have no medical condition warranting this surgery, unless obesity is a medical condition. Is obesity a medical condition? I have no co-morbidities, I am one of those lucky (or in this case unlucky) individuals who does not have any co-morbidities or required medication (I don't even take multi-vitamins) that would fast track me to approval. So now, here I sit, so close and scared to death I will not be approved. I guess if I expect the worst and hope for the best that I cannot be disappointed, right? wrong!! I have always be so glad I am "healthy" and now this may be my downfall. My BMI is over 50, yeah I never knew it could go that high either, but it is setting in that I could be denied. I went into this not even thinking that but now basically I have jumped thru every hoop and now my future lies in someone's "opinion and interpretation" of my chart compared to insurance guidelines and coveage. I am so not looking forward to this last leg but am taking it one day at a time.

I too am concerned about my hair (yes I too am vain but I love my hair) I have spoken with my surgeon, nutritionist and pcp they all tell me the key is getting your protein in and you can take biotin as a supplement. So you know I can cut my hair short and it can grow back I can handle that but I want this surgery, I need this tool. Hopefully you can find what works and you too will be as excited as me.

I checked with my insurance company actually asked "if on the 6 month supervisory diet and lose weight will I be denied?" (I am not afraid to ask them anything). They said that how great the success or how bad the failure, any outcome from the diet would not determine acceptance or denial. It had to do with BMI at the START of my supervised diet. I double checked this with my surgeon's insurance specialist and they confirmed what my insurance said. Realize No one can answer that for you only your insurance company and surgeon and realize your insurance company has the final say.

You look great, I hope I do as well. But know that 2 lbs a week is 100lbs in a year! I couldn't image that without surgery you are doing great.

The reason for the liquid diet is that it shrinks the liver and makes it easier on the surgeon during the surgery less likely to cause any damage to the liver as it has to be moved out of the way during the procedure.

I think this question is best posed to your insurance company, the utilization review department in particular. Every insurance is different, mine just required that my physician follow me for 6 months, with me visiting him 3 times with no more than 2 months between visits. It did not require any special diet (i.e. weight watchers or nutrisystem) but we talked about changes I can make or did make, and what to work on to be more successful. The success or failure is not what is important, at least that is what my insurance plan told me. Yet another co-worker who chose to be covered by BCBS requires that you also participate in weight watchers or nutri-system during that six month diet. I am glad I checked with my insurance, as I did not want to have to do the structured plans as my life after the sleeve will require me to have made changes that last the rest of my life rather than last as long as I can pay for a plan. As far as the notes we speak about the changes I have made in my life and diet to support my surgery plan and life after surgery and he is making sure I am exercising, it is a good thing. You can also check with your surgeon as to what they like to see.

You know I usually have this wonderful idea of what I am going to write about, but not this time nope nothing, zero, zilch, zippo. This should be no surprise to me as this was also the weight loss I had recorded with me PCP this month on my second to last PCP visit, prior to submission to insurance. You know the appointment was great it was informative and my doctor is becoming my biggest advocate. I am so glad that I have such support from him. With all this happening, you would think that I would be getting excited about getting so close to my surgery date. Nope, still seems so far away that it isn't even real. I look at my calendar and I see all the days that need to pass and all I want to do is rip it up (but if I did that I wouldn't know where I had to be and when I had to be there!!). Everyone has their own reasons to do the surgery, their own motivation and their own goals. I was thinking about my goals, my motivations, and what will life be after this is all down. I have decided my goals are the non scale victories, those things that are taken for granted by so many without even thinking. I really don't care if my final weight is 150 of 170 or some other number, I just want to look good. To know that men and people are looking at me because I am beautiful not because I am a big woman. I just want one man to want me for me not for my appearance but you have to have appearance to attract men, I don't care what anyone says. It is all about first impressions, and I want those first impressions to be memorable because of who I am not what I am. I want to be able to walk into a store and try on a dress that is in the window and know they will have my size in that dress. Not some cotten stretch, print from a couch, frumpy fat lady dress. Just because I am large does not mean that I do not like to look good. And I do not care what anyone says just because it comes in your size (aka skinny jeans, spandex, short shorts, etc) doesn't mean you buy it or more importantly that you will look good. I would just like to be able to feel good about being me is that too much to ask? I am not sad I am not mad I am just tired, why can't people see past what we look like. I promise after I have had surgery and I am making my way towards my new beginning I will never ever forget what this feels like. So basically, right now I am feeling life pass me by, I want to live my life and have someone live it with me where everyday is an adventure. I want to be involved to reach for and get that brass ring. I know there are a lot of people out there who know exactly what I am saying, so I won't go on. Oh and no matter who small I get I will NEVER EVER buy anything at Abercrombie & Fitch, I hope they go bankrupt.

I have a 6 month supervised diet plan as well. I am on month 4 now, and it seems like I just started. I had the same thoughts you did, what did 6 months matter. But you know what I have been able to make even more progress and this last visit with my PCP was so good we talked about things I never thought I would find helpful. You too will have that ah ha moment and you will find that this 6 months was needed. Good luck we will be here for you. It will pass quickly.

I would go to the ER and have it cleaned and the closed with either Dermabond or Steri-strips or a combination of both. I would be more concerned about infection if you close it yourself. Just say better safe than sorry.

My insurance said that as long as the BMI was at a stated level at the start of the supervised diet, it could not deny me based on my success or failure of this supervised diet. Check with your insurance

You need to get your protein and hydrate along with exercise. Take your kids on a walk, push them in a stroller, go to a park, but make time to move. The more you move the better your back will be as the weight will go. But stop eating late that can't be good.

It can also be a reaction to the anesthesia along with the pain meds that were/are used on you and it has finally metabolised. It is not uncommon.

It has been awhile since I blogged, I think that is because the snow finally melted, yeah!!! Ok back to the reason for my entry. For those of you who have not followed me or know where I am....I am currently in the last 3 months of my pre-op diet and I am losing weight. Cool right, but what is not cool is my surgeon's insurance specialist not communicating and when she does it is obvious she is clueless......."Ain't nobody got time for that!" I have emailed her repeatedly, giving her in excess of 15 business days to respond, nothing. I have patience but I do not have time for being ignored. And when she does respond it is like she has no clue what my insurance coverage is, or what my requirements are! The last straw came the other day when she told me that I had to see a doctor every month for six months (when my insurance requires 3 visits in six months). I know because it is spelled out in the plan, I pointed this out and she said oh sorry my mistake! Really, are you serious? I have no patience for this, the hoops I am jumping thru seem so tedious and I am determined to do it right the first time. So the next email I had a time sensitive question (which I have called and left her 4 messages on in the last 4 weeks no call back also) and guess what she NEVER responded. It had to do with me having the option of changing insurance coverages, well I had it so you know what I emailed the surgeon directly. Now we will see what happens next.....either they will hate me all around or they will appreciate the heads up!! Either way it needed to be said. Do people not get it that this is the BIGGEST thing to happen in our lives short of just a few other things in life..... AIN'T NOBODY GOT TIME FOR THAT Ok I feel better now No one is standing in my way of accomplishing this.

I too have a very high BMI, embarassing but it is what it is. When I met with my surgeon the first time after all the pre-testing and transfer of my pervious medical records, he told me that he would normally not recommend the sleeve to someone with as much weight loss as I wanted. However, due to my resting metabolism rate, my medical history (I have no co-mordities) and my activity level he believes I can be successuful with the sleeve. He is concerned with a possible stall at 6 mos, which he said he will watch closely and believes we can overcome it based on my history. I know this is not the cure and that it will take lots of hard work and the road is long, but I am in it to find that fit woman who is covered by all this protective padding. You and your surgeon have to agree with the plan, and ulitimately the decision is yours but make sure you make the decision for you and only you not your surgeon. I know if my surgeon had told me no to the sleeve, I would have stopped the process. I would have walked out and never looked back, maybe he saw that in my eyes too. Who knows what he saw, all I know is this surgery is for me, just make sure you are making the decision for you. Good luck.

I have heard from another member who takes Biotin regularly (and started couple weeks before surgery and she has had no increased hair loss. That was a huge concern of mine too.

Lisa, I have been thinking about wls ever since it became a procedure that insurances would think of covering (so years), and I too work in healthcare (ER at a level 1 Trauma Hospital). Not sure what you do in healthcare, but as much as there is not a light duty in our field, we both know that if need be we can get the help we need to lift the patient or anything heavy. I have not had the surgery, but am just waiting to finish my 6 mos supervised diet, I hope to have the surgery July/August of this year. This 6 month period I am finding is giving me comfort as the more information I gather and get closer to my goal of surgery. I read the good and the bad, take it all in, similar to attempting to get a complete H&P from a patient who has short attention span who keeps getting distracted. Everyone's story is so unique, take them all in and make the decision that is right for you. The complications from this surgery are similar to those of other major surgeries, up to and including the possibility of death. But you have to weigh out the pros and cons for YOU this is your decision. I have not found anyone, even those who have had complications. who would tell you that they would not do it again, although I am sure they are out there (this does not include those individuals who have passed due to a PE or complications from surgery). The hospital stay is normally overnight or longer if you have complications or pain control issues. As far as if I have I told friends, a couple very close friends, but no I am not telling my co-workers as a whole, it is very personal to me and my decision that only I can make so I will only tell those who need to know. I know I will be out of work for 2 weeks (as there are driving restrictions imposed by my surgeon). I don't know if this helps, feel free to message me privately if you have any questions that you are not ready to post. This is a great forum and good luck.

I asked my insurance specialist at my surgeons the exact question yesterday. She told me that as long as I met their requirements they could not impose a special restriction like you lost too much or are losing satisfactorily without surgery. This is your choice. If you meet their requirments (or exceed them by losing more yet staying within BMI ranges) they cannot deny you. She told me that this happened one time and the insurance company denied them she applied on the grounds stated above (meeting all requirments) and has never been turned down due to losing too much weight. But insurance has denied if you dont lose the required weight. Just do what the insurance requires.

I just met with my insurance specialist at my surgeons and was told that they can not deny based on the fact that I have lost or losing weight prior to surgery, it all has to do with BMI and other stated requirements. I would check with your insurance and ask them.

Your weight loss is amazing, I hope to see the same success once I am sleeved (coming up soon). However, I was told by my surgeon, that I could run into a stall around 6 months. And this sounds like what you are seeing. He told me this was due to the amount of weight that I wanted lose (and it seems we both are pretty close to goals). He said that if I noticed a stall, it could be taken care of and not to panic but it was possible. Being that we both have a lot to lose, more than the average on here, I would assume it has to do with the amount of weight we are shedding. So my suggestion is to go back to your physician or nutritionist as it is something they can help you with.