Wondering If Decision By Insurance Company Can Change - Different Situation

[workingmotherofthree 24]

Ok, so I went to the weight center in the fall of 2011 and went through all the classes, psych eval, nut, weigh ins, etc and paid my surgery track fee....Then found out that my husbands bcbs ppo national account had an exclusion on bariatric care. I even went and was was diagnosed with obstructive sleep apnea, which i am glad i got the CPAP as I am sleeping better and my husband says I am not snooring as much as in the past, plus on this account! So, I wrote a 6 page letter outlining my history....Please don't worry after you read this, but when I was almost 20 I was crossing the strret in college, of course in the middle of the night with all the athletes before spring break trips for sports and I was hit by a 55 mile an hour car crossing the street. I broke my back, pelvic, had Filled up with Fluid in my legs and the hip I was hit on, plus fracturing my skull and damaging my neck. No worries, I survived, but was told I would never be able to play sports like I did because of the injuries and were bad, but that didnt stop me. i learned to re-walk and care for myself....then the following season I wanted to just try to play soccer knowing I had ,issed softball all varsity sports, so I didnt want the driver to determine my fate.....Coach and the team were so excited to see me dressed.....I walked out on the field took one pass to me and as I crossed half field to kick it in the goal, which would have been easy for me....i kicked and felt a horrible pain through my body...shruuged it off, asked for another one thinking I could pass and low and behold body told me H..LL NO. I hugged the team and said sorry I just can't do this. The trainer drove me back to the lockers and that was the last time I was ever on the field until I had children...but before children I had surgeries to remove fluid off my hip and legs, but it will always be there. I was healthy at 180 lbs just not as muscular as I was in the past. So having children, wasnt sure that could happen based on the drs reports. So my husband was told this on our first date because I decided I didnt want him to get connected unless he was aware, yes he laughed...i already went through a long relationship and he was different than anyone I had ever been with..he says its because of the accident and I say its because he made me laugh. Ok, got preg for our first, deemed high risk...now the drama, the found a fibroid growing beside our baby...i was watched every week. Anyway was put on bed rest, the day of the c-section was def a comedy show, i had 2 surgeons in case I needed emergency hysteroctomy but when they said our new son was fine, they asked if they could take pictures of the fibroid as it was large, we asked them to remove it, but it was too dangerouse and I could die from blood los, etc so they tucked it back in my uterous and my life has never been the same. I couldnt loose the preg weight due to the pain on my back...so the dr told us if we wanted another child now or never...so they helped us get preg for our second...the fibroid grew, we ended up aving an emergency c-section 7 weeks early and our daughter was 5 lbs, again too dangerous so tucked fibroid back in. Anyways, i finally had enough....went in for an eval for the hysterectomy and after them saying no more and we couldnt get preg again, surprise of our lives we were. Thought we lost the baby cause I was bleeding and they didnt expect the baby to make it. A nurse at my work gave me shots to help me along....needless to say, our third was taken emergency c-section if you couldnt guess but she was over 8 lbs abd healthy...me on the other hand not so much....the re-oppened me that night as I had a major infection. I was then packec at home for months to heal, but we had our last baby...tubes tied as well. Now to heal, 2 yrs ago I had an ablasion to stop the horribly female cycles due to the fibroid, but it didnt help with the size....i am getting to my question, but figured you needed this background....so now its been 10 yrs, our son just turned 10 but had the fibroid for 11yrs, now its pushing on my bladder and I drip all the time, uterous is pushed uo as its inside the wall, constant back pain and it pushes on my pelvic and back.....so, this 6 pg letter was just captured in this paragraph...but it was to my husbands company as we would out there is an exclusion for weight loss. Needless to say, I self paid all the previous apts but stopped going as we wrote the letter to see if they would waive the exclusion...YES after 5 months of follow my husbands HR team overrode the exclusion and worked with BCBC to approve me. Now my letter said verticle sleeve, but they wrote a note that after review they approved the bypass......NOW what...they are working on how to notify the drs and Heres my question.....what are my chances of getting the sleeve? Can i loose over 100 lbs?? Also my uterous is enlarged so i am worried about bypass and only wanted sleeve! I dont know when I will be able to go back to the dr, but now that I have ben waiting and got the news wasnt sure what your thoughts are on getting them to agree to sleeve versus bypass. Thanks for listening! I read all the discussions and guess this is my largest post. Thanks again for your time.

[RickM 1,747]

If you need to use NSAIDS like aspirin, ibuprofin or naprosyn for any of pain issues, those are a big no-no for bypass patients, and are often used in appealing insurance decisions that favor the bypass over NSAID friendly procedures like the VSG or DS. 100 lb loss is very do-able with the sleeve and almost seems to be a sweet spot where the sleeve works very well while the RNY and DS are a bit of overkill for many (I lost about 105lb in a little over seven months with little effort, and could have lost more had it been healthy for me to do so; many have lost 200 or more.) Why BCBS approved you for the bypass and not the sleeve is anyone's guess, unless they provided some reasons in their correspondence; some companies reserve the sleeve for patients with a BMI of 50 and above (who knows why - tho there are some years' old ASMBS position papers to that effect though those are long obsolete and some of the staff or consulting docs for the insurance companies are just old like RNY guys and aren't familiar with other procedures. But if you need occasional or continual use of steroids or NSAIDS, that is often enough to force the issue with them, or to get their decision overturned by higher authorities

Good luck in your efforts.

[workingmotherofthree 24]

Thank you so much RickM. I appreciate this information and will wait for my husbands company to provide me with the written approval to override the exclsion. I will then talk with the surgeons. Again thanks.