Hello from PA (P.S. Please send Hope)!

[Band_Groupie 3]

Hello all! I've been lurking:peep: here a few months and decided to join. I feel like I have so much in common with many of you already. BTW-I'm married, 49, 3 kids, 1/2 hour North of Pittsburgh. Today, I'm in need of hope/suggestions!

I've just started this process so I'm at the :confused:"Head spinning Off-Insurance maze-Where do I begin to scale this wall" :banghead:stage. I want to start out right on this forum, so I'll post my details and more questions under the insurance sect., but let me tell you in a nutshell why I need some encouragement.

I've got a low BMI (between 36/37), huge family history of obesity related health issues, but I don't have a diagnosis of any of, what I'm learning are the "Big 4" comorbidities (although I'm wondering if I don't qualify as hypertensive- been running 140 something over 90-96). I've got many minor comorbidities. We have Highmark PPO Blue - need BMI 35+ with comorbidities, 6 mo. diet (and no, I can't afford to self-pay:piggy:= 2 college tuitions).

After talking to my PCP (not real encouraging, but gave me Dr. names), I decided to attend 3 different hospitals intro. seminars to learn all I can (seems like most ppl. only attend 1, why?). I've been to 2 and the first one never even called me after and the second one called and said I probably wouldn't get approved. I see my PCP on Monday (wanted to start my 6 mo. diet then) and I attend the 3rd hospital's seminar next Thurs./13th.

Someone throw me a lifeline that this might still happen for me. What else can I do to qualify? I feel like after giving up hope I finally found the answer to better health and now I'm not yet "sick enough yet" to get it. Do I wait to get diabetes, hypertension and have a stroke or heart attack like my parents/siblings? As my husband put it- I feel like I'm "Circling the Drain". I'm such an up-beat person but I'm getting discouraged. Please send hope!:thumbs_up:

[MacMadame 81]

Every insurance is a little difference. Some will consider hypertension but some only consider it if you can't control it with medicine. That was my case and I think it sucks! :eek:

[ShiraSimcha 0]

I also have a low BMI - 35.2 - although I admit, I gained some weight to get my BMI up past 35. I really want to have this done...it's very important to me and I feel it's a solution for me to stop the spiral of yo yo dieting.

I also live near Pgh. I live in Jeannette so I am east. I went to Magees seminar on the 5th. I do have comorbidities - high cholestoral/trglycerides, asthma and arthritis so I think I probably will be approved. I called BCBS (same ins as you actually) and they said BMI over 35 and you're a go.

I hope you'll stay in touch!

[Band_Groupie 3]

Thanks MacM....Insurance . I don't get why in a business of numbers where everything is usually black and white that the insur. co. make this so "grey". I feel like it's a "game" and even if you think you're playing by their rules, you still might get denied (after playing 6 mo.) because you didn't know ALL the rules. Why can't they just spell things out ARRGH!... Vent over, sorry.

Shira- I went to a Magee seminar (held in Cranberry) also (BTW Dr. Eid was great if you haven't picked a Dr. yet). They're the ones who told me I would probably not get approved.:party: Do you have Highmark also? Are you on medicine for any of your comorbidities? When you called insur. did they ask about your comorbidities or just the 35 BMI...you're making me hopeful again...thanks!

[shassy 0]

I also have a lower BMI, about 42 when I started the whole insurance approval thing....now at 40.....and I have a DATE although it is tenative........insurance approval this week, but they don't anticipate any problems. I have some comorbidities, asthma, high cholesterol, arthritis, depression, and I failed my sleep study. I am going to AGH, Dr. Colella....I am familiar with the hospital, and they have good outcomes. Both Dr Colella and Dr Uchal are very nice and eager to answer any questions. The office staff is ok....but not so nice and eager to help with the initial stuff....I live 4 hours away and trying to get appointments coordinated was a bit hard. Patty the person who works with all the insurance stuff has been the nicest one and most eager to help me get everything ready to go.

[It's_Christine 0]

Consistent b/p readings >140/90 are enough for a diagnosis of high blood pressure. I would ask your PMD to make the diagnosis even if he/she would not prescribe medication. The treatment could be dietary changes and weight loss! Also I would suggest you start the 6 month supervised diet no matter if you are "sure" of being approved for insurance coverage. Most insurances will use the weight at the start of that process so make sure you "weigh heavy" that day. No I am not saying put rocks in your pocket but be real about this. Good luck and stay in touch.

[Band_Groupie 3]

Shassy- I go to the AGH seminar this Thursday...I almost cancelled, both because I was discouraged that I'd not get approved but also because I was frustrated with the staff at Colella's office...I'd left 3 messages and sent an email (to Patty) all with NO response...hmmm. I'll give them another chance when I go this week, but I've read lots of negatives about his staff...I'll keep you posted.

Christine- I'll try to my PCP to write hypertension in my file...she'd already talked to me about how to cut back on salt, diet, for the high BP last time. Maybe we could discuss my comorbidities each visit as well and note changes if this will help with insurance?

THANKS!!!

[It's_Christine 0]

BG,

I can tell you what I was told when I was in my 6 month supervised period earlier this year my weight and weight loss had to be documented each session along with discussion about diet and I had to report my approximate calorie intake. I also had to show a "significant" weight loss over the 6 months which was losely defined but I assumed had to be at least 5%. I lost 9% of my body weight and that qualified. I was told they need to see you can follow a "low calorie" diet plan (1200 cals or less for a woman) and lose weight to qualify for the band. I am not sure if they expect the weight loss to have an effect on the comorbids. I have BCBS IL and they have the requirements to qualify for WLS on their web site and I just made sure I did everything exactly as they stated. Again I have my fingers crossed for you and keep us updated!

[ShiraSimcha 0]

Groupie...go to the Highmark website. Dont sign in! Scroll to the bottom and on the very far right side there is a link that says "Medical Policies". Follow this and you'll come to a library of their medical policies. Put in "obesity" to search when you get to this library and you'll get the policy on banding. That will tell you EXACTLY what they require from you. That was where the very kind woman I spoke with sent me. I ALSO found out that I will possibly be able to have my "fat apron" or panniculus removed at some point and let me tell you...over the moon on that one!!!! I don't remember exactly if we discussed comorbidities or not.

I did hear Dr. Eid was the best and I did request him :rolleyes2: While Dr. McCloskey didn't specifically mention asthma as one of the comorbidities, I think it is one as well as degenerative arthritis which I have in my spine. I also have heart issues which I forgot to put down on the checklist they gave me. I have an irregular heartbeat and my mom died at 40 of a massive heart attack.

I would hope this would get me in. Good luck to you!!!!

Shira

[Band_Groupie 3]

Shira- Thanks! The Highmark site has been down for routine maintenance for hours now, but hopefully I'll get in before tomorrows appt. Got in, it's the same info. I've got, but I'll search a way to ask questions.

Just curious...has Magee called you back since your seminar to let you know if you're accepted?

Edited November 10, 2008 by Band_Groupie

[ShiraSimcha 0]

No, I haven't heard from them yet but they did say probably the start of this week so I am hoping today or tomorrow. :thumbup: