adagray

Once you pick a bariatric surgeon, I think normally their office will arrange all these tests for you (at least mine did). I've only gone for two visits and I've already had most of them done (except I have one blood test and sleep apnea test left). My surgeon's office said that they've never had to refuse anyone based on the psych test and they've done thousands of surgeries (center of excellence). They do sometimes have to refer for additional counseling, but never had to refuse surgery. The written psych test is really kind of funny. One of the questions is 'Are your favorite hobbies archery and stamp collecting?'. I'm sure its in there as a guage to make sure you are actually still reading the questions (its a loooooonnnng test), but I had to laugh out loud at that one. But, the test will probably show them if you have other possible psych issues (depression, anxiety, alcoholism, eating disorder, etc.). I have generalized anxiety disorder (controlled w/medication - lexapro) and it was funny to see so many questions that I would have answered differently prior to being on meds for this. But, even if I didn't have it under control, I don't think they'd refuse surgery. I think they'd just want to make sure I got it under control before surgery.

I'm glad to have found someone who is in a similar situation as mine. Just out of curiosity, do you have documented BMIs of 35+ going back past two years? I'm going to try to submit those to help my case. I expect I'll end up being denied as you were, though, but will appeal. Worst case, I will stay this BMI for however long I need to be approved. I'm certainly not gonna diet again just to put it back on. I'm done w/yoyoing. Anyway, back to your question, I haven't submitted yet. I just didn't get all my paperwork together in time and still have some additional tests to take care of that the surgeon's office ordered last Friday. So, it may be another couple weeks before I submit. Hope that the clinical policy does not change for the worse in the meantime. Interesting thing is that when I went for the psych eval, the therapist said that a lot of the insurance companies are dropping the 6 month diet rqmt because it really should not be necessary if you have documented history of dieting already. So, who knows, maybe Aetna will loosen up their policy. A girl can hope! LOL

Aetna has this rqmt for high bp. They say it has to be 'medically refractory' which basically means that it is still high despite 'optimal medical management'. Luckily for me, I have terrible white coat hypertension (meaning mine always spikes when I go to the doctor anyway) so I have lots of high readings at the doctor's office even if it is pretty well controlled otherwise. I am going for a sleep study as well, though, just in case my high bp is not enough. The silly thing is that if someone wanted to trick the system, they could just not take their bp medicine that morning. Or, take some pseudaphed (sp?). Not that I'm suggesting these things, but for someone w/high bp to begin w/its easy to get a high reading if they need one.

Hugs! I understand where you are coming from. My situation is a little bit different. I don't have to wait because of a 'waiting period', but Aetna requires the last two years BMI to be 35+ (I have comorbidities), but I happened to lose below 35 BMI in the past two years because I was on Weight Watchers. I am still gonna submit (showing a high enough BMI up to 8 years back) and hope they will approve, but I'm getting ready emotionally for the fact that they probably won't approve it. I will appeal, but no guarantees. I just tell myself that if I have to stay this BMI for another 2 years, its not that big of a deal. Its not healthy, but at least there is a light at the end of the tunnel. I saw my mom go her whole life struggling w/obesity, high BP, high cholesterol, and type 2 diabetes and taking insulin for it. And, she just got the surgery one year ago and lost 95 pounds. Soooooo, in the whole scheme of things, if I have to wait two years longer, I can handle that. I figure if it comes to that I will just concentrate on other things during that time other than my weight. Its a relief in a way. But, yes, I would rather get the surgery now and start getting heathier earlier rather than later. Kind of ironic that I could end up penalized for making such a good last ditch effort w/WW. In my final attempt, I did it for 2.5 years and lost 45 pounds, then gained 60 pounds last year. Ugh!

Out of curiosity, I was just looking up info the 'The Apothecary Shop' since this is a compounding pharmacy close to me. Here is a link in case you are interested: Custom Compounding Pharmacy It says that they can take a pill form of medication and turn it into a liquid. Now, what that costs or if insurance pays is another question, but at least it looks like it can be done. :tongue2:

I am curious about this as well. I still have a few months before I get the surgery, but I take lisinopril and lexapro every day and would need some way to get these down. I'm wondering if you have access to a compounding pharmacy if they can crush the medicines and put it into some sort of suspension liquid (like children's medicines). I would think this would be safer (to get the right dose) than trying to do it yourself.

If you go to your PCP for your physician monitored weightloss, then does Aetna pay for those visits normally? Or, is it one of those deals that the visit has to be coded as for weightloss and they won't pay those codes so its not covered? I'm trying to decide if I should go to my PCP for the diet or go to my surgeon's office. They offer a 6 month program for $750 that covers what is needed for the physician supervised weight loss. They also say that it facilitates approval to go through them (probably cause they know exactly how to document it). BUT, if I only had to pay my co-pay ($20 each time) to my PCP, I'd rather go the cheap route and go to her for the weightloss visits unless there is any other benefit to going to the surgeon's office. I suppose if I went to the surgeon's office they may be able to actually give me diet advice that is geared towards getting me ready for the post surgery diet. Anyway, just looking for any of your experiences and thoughts on this. My other question is under what circumstances can you do a 3-month diet instead? I don't hear a lot of people mentioning that on here, but it is in my documentation from Aetna. Honestly, I don't care if it takes 3 or 6 months, but if I am to spend any time on another 'diet', I prefer that it be geared towards teaching me something that I don't already know... like tips/strategies/habits that I need to develop to support my success after the surgery so its not a total waste of time.

OK, I'm a little further along in the process now so I thought I'd give you an update. I decided to go through my bariatric surgeon's office for the 'weight loss'. My co-pay is $40 for each of these visits which I am totally fine with. I just didn't want to have to pay $100+ that a normal doctor's visit would cost if it wasn't covered at all. They also recommended that I go for the 3-month diet. They said it is something new to them, but if I was willing to see a therapist and exercise person for those three months, we could try to submit and see if it goes through. I figure may as well try. I can see a therapist who works out of my PCPs office and I have a friend who is a Jazzercise instructor and can help me w/the exercise portion. I will pay her what she would normally charge for personal training. There is no guarantee that this will get me approved in 3 months, but I figure it is worth the try. If not, then I continue on for the 6 months. I feel like its all worthwhile because the things I am doing w/the nutritionist, therapist, and exercise are all things that will help me in the long run anyway.

That's great! Maybe she did some further research herself. I never really considered WLS for myself until I did the research. Now I feel like any doctor who would not support someone who met the requirements is very out-of-touch and behind-the-times.

I am just beginning this process, but I have read a ton of posts on here and never heard of anyone being denied because of noncompliance on the diet or not losing on the diet. I think its more important that you weighed in w/your doctor every month and that your doctor made thorough notes. The only problems I've heard w/the 6 month diet is if the doctor is too brief w/their notes or if too much weight is lost so that the BMI goes below what is required. Anyway, so try not too worry too much. I know it is hard, though. I am nervous about doing everything right as well. If you think about it, though, who is ever COMPLETELY compliant on a diet. On WW, how many people say they have trouble getting all their Water in or go over their points sometimes. And, then you talk about it in the meeting and try to figure out how to do better. Personally, I feel like its just part of the diet process.

This is one area which I'm not really sure of. It seems most people on here have had to do the 6 month diet for Aetna, but I have seen at least one or two posts from people on here who have done the 3 month diet for Aetna. I THINK it may just depend on what resources you have available to you. If your surgeon's office offers a multi-disciplinary approach, then maybe you only have to do 3 months. But, this is really just a guess on my part. When I went to the seminar w/the surgeon that my PCP recommended, I asked one of their patient liaisons and she had never heard of the 3 month diet. This particular surgeon has just started taking Aetna so they may not know all the ins and outs. Anyway, so I just signed up to start seeing their nutritionist in a week to start my 'diet' and I'm gonna bring the paperwork and ask her about it.

I'm not w/ATT, but the way I understand it, the requirements are the same for all Aetna policies (if weight loss surgery is not excluded from her policy - which she should check on to make sure). But, assuming its not excluded from her policy, here is a link that explains the requirements: Obesity Surgery Then, if it is not excluded, she should check how much they will cover. For me, they pay 80% so I have to pick up the other 20%. For other companies, they pay 100%. It also depends on the policy, if there is a max out of pocket cost or maximum that the insurance will pay. Those are all details that are specific to what the company negotiated, but I believe the rqmts (in the link above) are the same for all Aetna policies.

I don't have experience w/BCBS, but I would recommend selecting a bariatric surgeon and start working w/their office sooner rather than later on getting your preapproval. I went to a seminar w/the bariatric surgeon that my PCP recommended, submitted all my info to them. They just called me back today to go over it and to let me know I needed the 6 month diet (which I already knew I needed). I set up appointments to see their nutritionist to complete that rqmt. She asked for dates in March for mtg w/the surgeon and I asked if I could meet w/the surgeon earlier and she said no problem. This first mtg w/my bariatric surgeon also includes the EKG, psych eval, etc. all in the same visit. I also want to talk to them about getting a sleep study done since I suspect I may have sleep apnea as well. In any case, I figure I'd rather meet w/the surgeon earlier rather than later. That way if there are any additional rqmts, I have more time to work those out during the same time I am doing the 6 month diet. Also, on some insurances (as w/Aetna - which is what I have), I understand that if you have everything else done, you can submit for preapproval before the 6 month diet is completed and get an approval pending the completing of the 6 month diet (which basically says you are approved as long as you finish the 6 month diet). That is what I want to do so that I am good to go once the 6 month diet is over. :->

I think most doctors nowadays understand the benefit of WLS and given that you clearly meet the rqmts, would be supportive. The way I approached my doctor was that I made an appointment specifically to discuss lapband surgery and to get her recommendation for a surgeon. I too was worried that she would say to go on a diet. She's a new doctor for me, but has already hinted (very carefully) a few times that I should lose weight. I think doctors are in a tough position, though, because they don't want to come on too strong about telling a patient that their weight is a problem because many would take that personally or feel like the doctor is being pushy. So, I think sometimes the doctor is waiting for the patient to bring up WLS (rather than suggesting it). My doctor turned out to be VERY supportive and even excited that I am pursuing this route. So, you are probably worrying for nothing, but I think its normal to be nervous about it. As obese people, we are used to society blaming us for our condition.

I have Aetna too. For the Sleep Apnea to 'count' as a comorbidity, it must be 'clinically obstructive sleep apnea' which is defined in one of their 'clinical policy bulletins' (CBP 004 - Obstructive Sleep Apnea). If you bring up the clinical policy bulletin for obesity surgery (0157) there is a link to the cpb they have on obstructive sleep apnea. I think you need to be using a CPAP (?) machine... that mask you wear at night to help you breathe. All that said, I would still try to get your surgery approved. They might deny you, but then you can appeal.

Sounds like you are in a similar situation as myself. In my case, I do have comordities so my BMI just needs to be 35+, but here is my history... Year Weight Height BMI 2002 210 65 35 2003 208/230 65 35/38 2004 213 65 35 2005 207/223 65 34/37 2006 195 65 32 2007 178 65 30 2008 210 65 35 2009 226 65 38 The reason I have two weights for 2003 and 2005 is because I was pregnant those years so those are my begin and end weights for my pregnancies. My PCP said that she would be surprised if I was denied. The insurance people at my surgeon's office expect that I will probably be denied, but that it would be worth appealing because I have proof to show I was dieting (through WW) the ENTIRE time that my BMI dropped below 35. I was actually on WW for 2.5 years and have all my weigh-in books. ANYWAY, I don't really have an answer for you because I am just beginning this process myself, but I would just suggest that you can as many past weights as possible that show your BMI as higher previous to those two years. Its ridiculous that we should be penalized for TRYING to lose weight and gaining it back. And, on the flip side, if you can't show that you tried to lose weight before, they won't approve you either. Kind of damned if you do and damned if you don't. In any case, I'm just gonna submit and expect to be denied, then make as strong as an appeal as possible. I've also been advised by my PCP and on here that the more comorbidities, the better your chances. So, I'm probably going to go ahead and have a sleep study. I honestly didn't think I had sleep apnea (or even snored loudly), but when I was talking to my DH about it last night, he said that I do snore really loud around 2am and he pushes me over to get me to stop. Kinda funny that I didn't even know that. I have also abruptly woke up a few times gasping and coughing.

So, I got all the info from Aetna (my insurance) for what it takes for precertification. And, confirmed that I don't have an exclusion. Based on the precertification rqmts, though, I expect that this will be a fight for me to get approved. So, I'm wondering if it is better to apply for precertification before the 3 or 6 month diet to see what they are gonna fight me on. Or, are you supposed to wait until you THINK you meet ALL of the rqmts to submit your first precertifcation. The thing is that I would not want to do the 3 or 6 month diet unless it is going to help me get insurance approval. If I can't get insurance approval, then there's no point in doing that diet (at least not right now). So, here's why I expect a fight... Aetna requires that the last two years' BMI be 35+ (in my case, I have comordity of high bp which is not controlled well w/medication). But, my weight history looks something like this... 2002 - 36 2003 - 35 2004 - ? ( but less than 35 probably because I was on a diet) 2005 - 35 2006 - ? (but less than 35 because on WW) 2007 - ? (still on WW - hungry hungry hungry!!!) 2008 - 35 (but that was at the very end of 2008) Current - 37 So, I have a history of always returning to the 35+ range, but I always diet to try to get it back down so there are interspersed lower BMIs in my history. I expect Aetna to deny me, but that I may be able to get approved through appeal. If I can't get insurance to approve, then I don't mind staying at this BMI for however long it takes. Anyway, that's all just to give you some background. I'm really just wondering about the process of when to submit my first precertification request (before or after the 3/6 month diet). Thanks!

I know w/Aetna, you can submit before the 6 month diet just to make sure all other rqmts have been met. I think its a great idea that way if there is anything else they need, you can take care of it during the same 6 month period rather than wait until the end and be unpleasantly surprised that you are still not 'done'. Anyway, I would think this means you are good to go, but maybe check w/your bariatric surgeon's office to put your mind at ease. I know I'm gonna make sure mine submits everything BEFORE the 6 month diet so I can know if I have a fight on my hands.

I have Aetna too. One thing that is kind of confusing to me is why people are nervous about being approved AFTER they do the 6 month diet. From what I understand w/Aetna, you can submit for approval before the 6 month diet and know you are approved (contingent on completing the diet). I believe this is what my surgeon's office will do as a first step, but I will confirm just to make sure. So, do you know if you already have this pre-approval (before completing the diet). Maybe ask your surgeon's office, just in case. It seems they should all do this so you won't waste your time/money on the 6 month diet unless you know you are approved otherwise. Anyway, it sounds like you would be approved anyway as long as you can also show 2 years history at a high enough BMI and that you have no exclusion. Boy, this insurance stuff can be confusing, though!

Well, I saw my PCP today to talk to her about lapband and get a recommendation for a bariatric surgeon. I was halfway expecting that she might encourage me to just diet again instead, but she was totally supportive of the lapband. I told her that I was concerned that I might not be approved by insurance and she told me that with what she has to put in the letter for me, that she would be very surprised if I was not approved. My BP was up to 155/99 today (even though she just doubled the dose of my bp med a month ago). I have never been so glad to see it high, though. Its my only comorbidity that really 'counts' as far as Aetna is concerned. Anyway, I don't know why I'm even posting really. It just feels kind of surreal to start this journey. I am going to a seminar w/Scottsdale Bariatric Center this Sunday.

Personally, I had not thought of doing anything like this prior to surgery, but I think its really a personal decision. If it make you feel better and more positive, then that's great. I am actually one of those rare fat people who eats A LOT of healthy foods. I love vegies especially. costco has the best fresh brussel sprouts lately. I buy a 2 pound bag and roast them in the oven w/olive oil and sea salt. They are so yummy that I find myself snacking on the leftovers after dinner and even cold out of the fridge the next day. My problem is not only do I like stuff that's good for me, but I love the 'bad stuff' too like baked goods, meat, etc. If you are familiar w/Ina Garten (the Barefoot Contessa), I eat like that. I don't eat sleeves of Oreos and Fast food, but I eat a diet that is just too 'well rounded' shall we say. LOL Anyway, I just mention that because I don't think its accurate to say most people are fat because they eat badly. I think there are a lot of us who just eat too much in general, but not necessarily junk food. ;->

Thanks for your advice. I am actually seeing my PCP this coming Tuesday to talk about lapband and get her recommendation for a surgeon. But, I also made a reservation to attend a seminar w/Scottsdale Bariatric Center next Sunday already as well. Even if its not the surgeon my PCP ends up recommending, I figure it doesn't hurt to get as much info as possible. Anyway, I will definitely ask my doctor about testing for additional comorbidities. I had full bloodwork done in late November, though, and was a little surprised I don't show as pre-diabetic. I feel just awful when I eat high glycemic index type foods. But, I wonder if I don't test as pre-diabetic because I just avoid those foods now.

I can believe it. My mom's doctors have been telling her for at least 5+ years that she needed WLS, but she never wanted to do it. Honestly, she didn't really 'want' to do it when she got it done a year ago, but she had to do something about her health.

ROFLMAO!!! :confused: BTW, all my friends w/huge plastic knockers think its a great idea for me to get lapband surgery. I'm not trying to make any point by saying that, but I just think its funny.

I haven't read all the replies to this yet, but I am one that is looking to get lapband surgery w/a BMI just barely over 35. I'm 220 and 5'5" now, but a typical non-dieting weight for me is about 210-215. Every time I've gotten above 210ish, I get scared out of my mind and go on a diet. Every diet I go on, I generally commit really well and lose a good amount of weight (30-50 pounds). I just cannot keep it off and diet=hungry to me. People tell me I need to make it a 'lifestyle', but I have finally come to the conclusion that being hungry all the time is no kind of lifestyle. At the same time, I am so scared to gain more weight because I've seen all the pain and complication of morbid obesity by watching my mom deal w/it her whole entire life w/diabetes, high bp, high cholesterol, barely even being able to walk one block, etc. It sucks! (as I'm sure I don't have to tell a lot of you). And, I KNOW she tried as hard as she could. Anyway, so she finally got lapband one year ago (she is in her 60s). I'm turning 40 next year and don't want to wait until I'm older or fatter to deal w/this so I'm looking to get it this year (if insurance will pay) or two years if I have to keep my BMI up that long to get insurance to pay. Honestly, I couldn't care less about fitting into smaller clothes or what people think about my weight. I've been fat enough for long enough that I've just accepted that part of it. BUT, I cannot accept losing my quality of life and health because of this fat. And, I cannot deal w/losing it just to regain it again. I'm so done w/that! So, I hope that explains the perspective a bit of why someone who is barely over 200 would even want to get this surgery. And, I think anyone w/BMI 30+ should be able to get it by self-pay if necessary. I understand that insurance cannot afford to pay for anyone and everyone who might want this surgery, but I would hope that it would be made available to as many people who want it as possible. I just don't think there are a lot of people who want to do it as an 'easy way out' because if they are educated at all about it, then they would realize it is not an 'easy way out' anyway. Logic leads me to believe that most people would not go for this surgery unless they felt it was their last resort anyway. P.S. - Forgot to add that I have chronic high bp that is not well controlled w/medication even though I am on my 3rd med for it. And, recently got diagnosed w/high cholesterol. I also have another problem related to obesity that I'd rather not mention. I feel like diabetes is right around the corner and would be the nail in my coffin. I know that seems very overdramatic of me, but I am horrified w/this all because I've already seen my mom go through it all.