Borderline in PA

[rita326 0]

Hello everyone! I have a dilemma that maybe some of you have had - my insurance requires a 40 BMI or 35 - 40 with conditions. I am a 38 w/o conditions - yet. My doctor is sending me for sleep apnea testing but I can't get in until late July for a consult and probably August for the actual test. I don't see my primary doc again until late July. In the meantime the lap band doc's office called me recently because I attended a seminar and want me to come in in mid July for my first meeting. That will include my first weigh in.

My dilemma is I need to gain 12 pounds in less than 3 weeks (which doesn't sound difficult until you try it) or risk the sleep apnea testing coming back negative or I could hold off the weigh in for another month and have to wait even longer to have the lap band! Another issue is that you can't gain even 1 pound after your weigh in so I must be a 40 at least when I weigh in.

I can't wait another day! And I don't want to gain another 12 pounds just for my insurance company. This is killing me both physically and emotionally.

Anybody else having to go thru this? What did you do?

[Lunabeane 2]

Rolls of quarters in your pockets or what about ankle weights? You shouldn't have to take off your clothes for your initial visit.

I'm in PA as well. Are you in the Pittsburgh area?

[rita326 0]

I was seriously thinking about that. Do they measure you as well?

I'm from Indiana, about 50 miles NE of Pgh but I grew up near Monroeville.

[rita326 0]

Lunabeane, where did you have your surgery done?

[Lunabeane 2]

I live fairly close to Monroeville.

My Dr. didn't measure me during our consultation. My husband and I went together and sat in a room and discussed the procedure with the Dr. he did take my vitals and looked at pressed on my stomach. I never took off my clothes. I know that there were a lot of woman that wore weights and put weights in their pockets when I was attending my lifestyle classes. They were in a similiar position as you...right on the borderline of meeting the criteria for approval.

The medical assistant will ask you to remove your shoes and socks but that's it. At one time someone suggested that you could put fishing weights in your bra as well.

I would take those measures as well as drink a ton of Water before going into your appointment.

My insurance did not allow any weight gain during the six month lifestyle phase...there were times when I wished I had done the weights...but I ended up being able to take off 5 pounds during the lifestyle classes.

Good luck!

[rita326 0]

Thanks for the info, it just makes me sick to my stomach thinking about having to gain 12 more pounds. It goes against everything! With my schedule it's very important that I have the surgery before March so I don't want to wait another minute longer than I have to.

I'm going to Magee, I went to the seminar with Dr. McClosky.

I see you just had yours done, how does it feel? Aren't you just elated?

[ilse72 0]

Rita, I hate to tell you but, depending on your insurance, you may end up waiting an additional 6 months to have the lapband...if your insurance requires 6 months of documentation that you followed an approved diet plan. If your insurance doesn't require it, you are one of the very lucky ones!

I am also borderline but I have chosen to be a self-pay. That way, I can have my surgery asap without having to jump through the insurance hoops or without having to gain an additional 10 pounds. I just have to attend the seminar and have my consultation...and hope the doctor will decide to do surgery.

[rita326 0]

Mine does require the 6 months, but $20,000? I don't think my husband will go for it.

[ilse72 0]

Wow, Rita! $20.000?! That is high! Mine won't even be close to that!

[Lunabeane 2]

Thanks for the info, it just makes me sick to my stomach thinking about having to gain 12 more pounds. It goes against everything! With my schedule it's very important that I have the surgery before March so I don't want to wait another minute longer than I have to.

I'm going to Magee, I went to the seminar with Dr. McClosky.

I see you just had yours done, how does it feel? Aren't you just elated?

I had my surgery done at Magee under Dr. George Eid. I've had a wonderful experience with him and his staff. They have all been very supportive, except Rachel the PA, who I have some difficulty with. I've heard very good things about Dr. McClosky as well. I had my first fill today with Bill...the Nurse Practioner that does the fills for Dr. Eid. I was nervous but it all turned out well and he was just as supportive as the other people that I have been working with.

My insurance required that I go through the six month lifestyle classes that are offered at Magee. I went once a month for six months. During that time I was weighed each month and documented everything that I ate in a food log.

It took seven months from start to finish. I had to have an endoscopy, chest x-ray, upper GI, psych consult, blood work, and six months of lifestyle meetings before sending everything in for insurance approval. My insurance granted approval within 24 hours after submission and I was scheduled for surgery within a couple of weeks.

I've lost 23 pounds since having the surgery. I know that many people say that the period of time after surgery is for healing but I had enough restriction that I was able to successfully diet for the first time in seven years. I feel very good about my decision to have the surgery and wish that I would have made it sooner. I've been fortunate that I haven't had any issues...no nausea, vomiting, or pain since the initial recovery period.

I have two friends that have also had their bands done at Magee...one by Dr. Ramanathan and the other by Dr. Eid. Both of them have had very positive experiences as well. I can't say enough about the nursing staff that took care of me after the surgery. Once I was in my room and on the pain pump they took wonderful care of me and were very supportive and positive. I think you made a good choice.

[Lunabeane 2]

My surgery cost approximately $40,000.00. That included everything. My insurance covered everything but my lifestyle meetings and several copays of $20 or so. All of my fills are covered and any issues that I have with the band are covered as well.

Also, you should know that they were very supportive of my timeline. as a teacher I had a very narrow window of when I could have everything done and return to my normal teaching load. They made sure to accommodate me in every way.

[rita326 0]

Why did it cost $40,000 when they advertise only $19,500? If my insurance doesn't cover it I'll be screwed for sure coming up with 40. Thank you so much for sharing your experience with me, I'm so glad to have someone to talk to who actually went to the same doctors I will be seeing.

You know, that's not the first time I've heard something about Rachel in their office and I've only just started looking at this site this week. She must be a real pip. I bet she's the one that answered the phone when I called the other day asking questions.

I bet you can't wait for school to start this year, what a great feeling!

It's nice to be able to talk to people who have actually had the surgery, I don't know anybody who has had this done but I know plenty who should. How's everything going with your first fill? What are you able to eat at this point?

[Lunabeane 2]

Rita,

I never knew that there was a price quote of $19,500! Had my insurance not covered my surgery I could not have afforded to get it done...not if it were 7,000 or 50,000! What insurance company do you have?

I have UPMC Panther Gold health insurance. Had you come to me last year I would have told you that they were garbage...but they came through for the surgery! So...I'll be nice about them for now.

The last bill I received for the actually surgery was $33,000. Insurance paid $16,000 for my upper endoscopy and for the upper GI and chest x-ray (not sure what the cost was for that). I wonder if the quoted price is just for the surgery and not for the OR and all of the other stuff necessary to do the surgery? Melinda is the person that took care of all of my weight management and food log stuff and Robin was who sent in my insurance approval documentation. I would call and ask them if they deal with your insurance company on a regular basis and if they often cover all of the expenses. I've heard that Kelly, one of the PA's, is absolutely wonderful. Also, one of the Nurse Practitioners, Deb, was my life line after surgery. Everytime I had a question she answered it in a kind and sensitive manner. She never seemed to get irritated.

I'm feeling good after my fill, thanks for asking. I took it easy yesterday, only eating cottage cheese, yogurt, and some chicken salad. Everything worked out well. Today I had my very first salad since being banded. I took it slow but it worked out well. I've been craving salad...who the heck would have thought? I'm not sore and not sick...the two things that I was worried about.

You know, rita, I know that people have some horrific experiences, but I have found the Drs. in this practice to be conservative and thorough. There aren't any corners being cut and they are running a top notch business. Now...mind you...I am not a huge fan of UPMC but these Drs. seem to set themselves a part from the larger UPMC monopoly.

Please let me know if there is anything that I can do to make your journey easier. I have every document that I was given since my first meeting with the Dr. Just start getting all of those pre-requisites taken care of. Get your appointments taken care of early on. As soon as Dr. McClosky give you the script to take care of all of the pre-requisites call and make the appointments on the first day. Also...if your insurance won't cover them..call and ask your PCP to write scripts for the same things so that it appears that he is asking for the documentation. My insurance didn't require any referrals...but yours might. My friend took the script from the surgeon right to her pcp and he wrote scripts for the same procedures. Everything was covered.

[rita326 0]

At the seminar the prices were in with the paper work, the lapband is $19,500 and the gastric bypass is $27,000. I think that is just the surgery, none of the extras. My insurance is BC/BS Special Care. I'm really surprised it will cover it because it doesn't seem to cover anything else but I do need to be 40 BMI or more by July 17 or have a major pre existing like Diabetes (don't have . . . . yet but if I keep gaining and losing like I am it won't be long) or sleep Apnea which I will be tested for in August. I'm wondering if I should delay my first weigh in until after the sleep apnea test. I don't know, I just want to get started with my 6 months and get on the right track. I'm not a very patient person I guess.

[Lunabeane 2]

rita,

I started my six months lifestyle meetings before meeting with the surgeon for the first time. Also...the office isn't going to send anything in to the insurance for approval until after you finish the six month lifestyle meetings. Which means that there might be pre-existing conditions that will be determined through all of the testing.

For example,

Arthritis

PCOS

Insulin Resistance

Acid Reflux

High Blood Pressure

High Cholesteral

Back Pain

Knee Pain

sleep Apnea

Asthma

These are things that you should discuss with your general practioner as well. If any of these comorbidies have been discuss and documented with him/her then that qualifies. I would begin the classes and start getting them out of the way...do you first weigh in with weights and heavy heavy clothes as well.