New, and in need of some insight!

[kyra112 0]

Heyyy!! So like my title says, im new here, and i just have some questions about this whole process, but to clear something up im trying to get approved for bypass surgery, not the band, but i hope im still welcome? Lol. Well i suppose ill let you guys in on my situation. Well my name is Kyra, and im 17 years old, i graduated early, actually just a couple weeks ago, and i have been pondering this surgery since last year, and now i know i want it after a 4 month FAILED Nutrisystem diet attempt. Ive struggled with weight literally my WHOLE life! It's just in my genes! luckily, i have no developed anything life threatening, although recent blood tests indicate high glucose AKA borderline diabetes, and my mom btw is a full blown diabetic, with many comorbs, and her and i are trying to go through this together. Ive been on SO many diets since about 6th grade, i commited to all of them, but it was the same old lose 5 and gain 20 lbs deal, so i know i need this. Anyway, i guess i just have some questions on the whole process. Mainly the PCP referral deal. I seen my PCP in September, and although she admits this surgery is medically necessary for me, she is against the surgery, even though she hasnt outright says it, my mom and i can tell, and my problem is she made me do all these blood tests and she is very unreliable, she has cancelled on my at least 6 times, and she keeps putting it off. So anyways, here i am, 4 months later and no referral. So my mom and i called the surgery office and they said that they dont need a referral, just insurance approval, SO im wondering, has anyone been approved without a PCP referral?Im going to call my insurance [which is TRICARE btw] on Monday, but im afraid they will say i need a referral and it is like pulling teeth to get the referral from my PCP. I would also just like to know the approval process many of you went through! It would just be nice to see what I am getting into! And here is my info:

5'4'', 275-280 lbs, medium frame according to MET table, BMI 47.

I heard tricare doesnt care about BMI, just if i you have comorbs OR if you are 200% over ideal weight, which is the criteria i meet.

Thank you all so much, and God Bless!!!

-Kyra:cool2:

[fourme 0]

Hello Kyra,

You have a couple different things that need to be addressed, number one your PCP is an issue. If the MD has canceled 6 appointments, you really should consider another PCP. You have to have a PCP that is going to work with you. I don't believe insurance will consider approving without the PCP supporting you, you will also need a psych eval, and many other requirements, depending on the program you choose you may need to attend support groups and jump through a lot of hoops.

#2 You have to be able to loose ten percent of your weight and show that you can be on a diet and you have to commit to exercise.

#3 If you don't mind me asking, why are you choosing bypass at such a young age? If you were to get into a program and loose the 10% you could have a lapband and would not have to deal with the malabsorption and the other complications relating to bypass?

I have just had my surgery and it was a realtively long process to get to this point and now that I have the surgery it is still 100 % committment on my part to make this work. I have to follow a very strict diet for the next 6 weeks. Then have to stick to diet and exercise. Anyone considering weightloss surgery has to understand that this is a huge step to make and is in no way a quick fix. Good Luck with all that you do and I hope you are able to get the answers you are looking for on our site. If there is anything else I can do to support or assist you in any way please let me know!

[kyra112 0]

Thank you for answering! So the deal with my PCP is complicated, because i technically cannot "choose" my PCP because mine is like, assigned to me because im american indian, so the whol free medical thing works in and i end up with her, and in order to change my PCP it would be a long and grueling process in itself, i live in Alaska btw. And i am aware of all the support meetings, and the psych eval but the surgeon said that we will deal with all the stuff after approval. And the reason I am doing bypass is just because i am more familiar with it i guess, ive known people who got it and got wonderful results, and although the band might be equal, i heard that sometimes it might not work if you don't "Eat right" or it can still absorb sugars and things like of that sort, and my thing is that i've had a bad relationship with food my whole life, and i feel the bypass will force me to re evaluate and re-establish that relationship with food for the better! Also, by what ive read from other people who have Tricare, is that they approval process for bypass is a lot faster, which is what i need because i start college next fall so i can use all the time i can get! But thank you so much for replying!!

[newgirlinwa 0]

I have been approved for surgery without a PCP referral. I did everything through the weight loss surgery clinic I go to. As long as I fulfilled Aetna's requirements, I was good.

Michelle

[SoccerMomma73 1,867]

Good luck with the process and your surgery. I would encourage you to investigate the lap band further before making a definite decision. I'm a family practice physician assistant and have at least 6 (probably more) patients who had a gastric bypass, lost a bunch of weight, and now weigh more than 300 pounds...they just ate and ate until everything was stretched back out and now it's like they never had the surgery. Yes, the lap band diet is tougher butyou're likely to be healthier in the long run....Again, good luck with everything!

[Manda87 3]

I went to my PCP to talk to her about my lap band surgery. Basically, I paid my $20 copay to have her tell me to talk to a surgeon. Lol. I found a surgeon that I liked and we got the ball rolling. I'm just waiting for them to set up pre tests. After those results come back, they will submit to the insurance.

Before I saw the surgeon, I called the insurance. They are soooooo unhelpful. They want to be paid, but when it comes to actually getting money from them - it's like pulling teeth. I even got three different quotes from them.

Good luck!

[BigMomma 0]

Kyra-

It depends on your insurance requirements. Mine didn't require PCP referral. Good Luck!

-Val

[kyra112 0]

Thank you all so much! you guys have been very helpful. its good to know some of you didnt need a referral, and its not stated in my insurance that i need one, so we will just see what happens when i call them Monday, i hope i can just do it through the surgery clinic, it sounds much easier, and less stressful! And christiemr, thats one thing im afraid of is gaining the weight back, so i think i will look into the lapband i bit more, I'm not against it or anything, but so far bypass feels right for me, but i will still look more into the band! Thanks again guys! I will keep you guys updated.

[MsShay 0]

I am Tricare (Triwest to be exact), I just had my lapband surgery on Dec 28th. I did not go through my PCP. I went directly through the surgeon. For now Tricare does not deal with BMI but they are in the process of changing it. It appears from your height and weight you woud probably meet the 100 pounds of your ideal weight according the Met Life charts. I say go through the surgeon. My PCP was against the surgery however when I had a follow up appointment with her last Friday she was excited and was showing me around. Its your decision and make sure you are doing what's best for you.

[kyra112 0]

Thanks Ms.Shay! its encouraging to know we have the same insurance, and you didnt need a PCP referral. But another question i have for anyone who has tricare, or i suppose and insurance for that matter, is if you were denied , why?

thanks again guys !