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jsm

Gastric Sleeve Patients
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Posts posted by jsm

  1. Posted

    Well, my appeal has been received, and they have 15 days to respond. I do know that my surgeon will be doing a peer to peer appeal for me too. I have already started my pre-op testing (sonagram, chest x-ray, barium swallow and 15 tubes of blood yesterday). I just wish I had the final decision so I could plan my next steps. I could probably swing $5,000, but $9,500 plus air would be out of the question right now. The sad thing is my surgeon is supportive of the sleeve surgery.

    I'm still trying to keep that positive energy flowing. :drool5: Has anyone had their surgeon go to battle for them with the insurance company? If so, what was the outcome?

    Hugs,

    JoAnne

  2. Posted · Edited by jsm

    CareFirst BlueCross BlueShield of MD approves the following:

    • Adjustable gastric banding (e.g. Lap BAND?)
    • Gastric bypass
    • Gastric stapling
    • Biliopancreatic bypass with duodenal switch
    • Sleeve gastrectomy, performed either as a stand-alone restrictive procedure, or as a first stage procedure of a planned biliopancreatic bypass with duodenal switch for patients with a BMI exceeding 50

    Since my BMI is 41, I don't meet the VSG qualifications, but I do qualify for gastric banding or bypass. It truly makes no sense that VGS will be approved as standalone for BMI > 50. If my BMI was > 50, I would be approved for Gastric Band, Gastric Bypass or VSG,

    I have submitted my appeal with tons of documentation on the latest VSG studies, and my surgeon has request a peer to peer review with the Medical Director of Appeals. Hopefully they will get the message.

    I do not know what the outcome will be, but I will not go down without a fight. With that said, I'm afraid I will be forced to cave in to RNY. I need to start my weight loss process asap. I can barely fit into any of my clothes, and I refuse to go out and purchase larger sizes.

    I am still trying to keep my positive attitude, but I feel myself wearing down.

    I'm so thankful for all the support everyone has provided.

    Hugs to All,

    JoAnne

  3. Posted

    Carolyn, will keep you in my thoughts and prays for a safe surgery and speedy recovery. Can't wait to read your updates!

    Steph, I totally agree with you about the health care hoops. I work for CareFirst BlueCross BlueShield. I am very familiar with the pre-cert process, and was so careful to make sure all my I's were dotted and T's crossed. Well, in my appeal, I have pointed out that the Position Study referenced in our Medical Policy for Obesity, is no longer available on the WWW. I'm hoping that in itself will be a factor for approval. I have provided many references of recent VSG studies. Additionally UHC, our competitor has reversed their Medical Policy this month stating that VSG is proven in adults for the treatment of clinically severe obesity (35-39.9 kg/m2 - Obesity Class II (Severely Obese)). My CareFirst Medical Policy will only approve if BMI > 50.

    I truly believe that the tide is slowly turning with physicians, specialists and Health Care Insurers, seeing the benefits of WLS. Recent studies for VSG can only help to get this procedure approved with the same criteria as RNY and Gastric Banding.

    Should my appeal is denied, I will have to regroup and reconsider RNY or self pay in Mexico. However, I'm still not giving up hope for approval!

    Hugs to All,

    JoAnne

  6. Posted

    Thanks all for your support.

    I have fulfilled all the requirements PLUS, specified by my insurance company. Additionally, The UM Center for Weight Management & Wellness has additional requirements before they submit to insurance. I made sure my clinicals had every I dotted and T crossed.

    What I'm frustrated about is that my member services told me months ago that the sleeve was approved, but never specified the BMI requirement of > 50. I also got a copy of our Medical Policy, and it reads like it's approved as a standalone OR as a first stage with DS later for BMI >50. I sat down with one of our Medical Nurses this afternoon, to get her take on the policy. While she agreed with me, if you go further down in the fine print, you fine the AND between the two procedures.

    I will be approved for RNY, but NO WAY! (I'm saying this now!). I did not spend months of research on procedures that I'm not comfortable with.

    I'm not giving up hope yet. I will pull together whatever studies are out there and submit an appeal. I know who to go to, and will speak with them in the am.

    If it is not approved, then I will just need to save my $$$ to go to MX. I know Dr. Aceves is the best, but he is running no specials and the price not including air is $9500. I see there are several other "all inclusive" with Dr. Fransico Gonzalez, DR. Lisa Marie Gonzalez (LIMARP), Emmanuel Medical, The Bariatric Group.

    Does anyone have feedback on these practices/surgery centers, OR any other personal recommendations of MX surgeons ?

    Your Help is greatly appreciated! I knew it was too easy up to this point (everything fell into place like magic until today). However, this too shall pass!

    Hugs to all,

    JoAnne

  7. Posted

    Thanks Chancie.

    Although I've only been communicated to verbally, I've already made some internal inquiries on the best way to handle the appeal process (thank goodness I have some great connections).

    Anyway, I need to get some of the latest studies that have been done recently in the USA on the Sleeve.

    If anyone has any of this info, would you please post the url's? This is coming at the worse time for me, since I have a huge work deliverable due Friday. Any help will be greatly appreciated! I do have some information that I've compiled for my own documentation, but I did not include the links (dumb me).

    Thanks everyone for your support and the support you provide to the members of this forum. The information and sharing here is invaluable.

    Hugs,

    JoAnne

  8. Posted

    OK.....I work for CareFirst BlueCross BlueShield. I was told by our member services that the Sleeve was covered. I also looked at a copy of our Medical Policy, which states:

    Sleeve gastrectomy, performed either as a stand-alone restrictive procedure, or as a first stage procedure of a planned biliopancreatic bypass with duodenal switch for patients with a BMI exceeding 50

    So, assumed that since I was just having a stand-alone restrictive procedure, there was no BMI associated with that. However, it appears that CF will only cover the sleeve for patients exceeding 50. This makes no sense to me.

    I'm ready to throw-up and cry!

    I do not want the bypass. If I appeal, my date of 11/10 is out the window. :confused:

  10. Posted

    Thanks all!

    I started "freaking" out this morning when I found out my surgeon uses a tight 40 F! :confused1: My surgeon assured me that the difference between each size is about 1/10 of an inch (32 - 34, 34 - 36, etc.). This would make 4/10 of an inch difference between a 32 and 40 - less then ? inch

    Immediately I tried to find the actual size of a bougie. If my research is correct, then .333 mm is 1 F.

    .333 * 32 = 10.66 mm

    .333 * 40 = 13.32 mm

    A difference of 2.66 mm. But 2.66 mm does not equal ? inch.

    Do my calculations sound correct? Can anyone validate the correct size of each bougie? :huh0: Realistically, there does not seem to be much difference between these sizes, and I should not sweet the small stuff! :w00t:

    Thanks for any input!

    Hugs,

    JoAnne

  11. Posted

    Hi DeeDee and Jen,

    I'm going to the University of MD. Dr. Kligman will be doing the surgery. Would love to go to Dr. Aceves, but my insurance is picking up most of the cost, which enables me to stay local. Dr. Kligman has a wonderful program and know I will be in great hands. I have about 100 lbs to loose, and my BMI is 41.

    Can't wait to read and share all of our experiences through this journey!

    Hugs,

    JoAnne

  13. Posted

    Just found out today that my surgery has been scheduled for November 10th. I am so, so excited and ready to become a sleeve sista! :thumbup:

    Now I have to go back through the posts to figure out how to setup my weight loss ticker...etc.

    All I can think about is this time next year I will have a brand new body (probably in need of a lot of tucks, but I will deal with that after my new body arrives)!:incazzato:

    Hugs,

    JoAnne

  14. Posted

    If we could loose weight ourselves, and keep it off, we wouldn't need surgery. WLS is not a gimmick! For most of us, it's the last hope we have after trying everything else out there.

    Stick to your guns Nancy! You have selected a tool that will finally help you to be successful!

    If your hubby won't support you, find a trusted friend who will support you through your journey.

    Best of Luck,

    JoAnne

  16. Posted

    Interesting on the H-Pylori diagnosis. I just found out yesterday that I have it too. Getting ready to pickup my prescription. I never heard of this before. Didn't have any symptoms, don't know how long I've had it, and never would have known if I wasn't having the surgery. :001_tongue: My Dr. told me that they will just check my breath to see if it's cleared up.

    Has anyone else been diagnosed with H-Pylori? Is it common? :thumbup:

    Hugs,

    JoAnne

  19. Posted

    Suzy, don?t give up hope. Call your BCN member services in the morning and ask them what their Medical Policy is for Bariatric Surgery. Make sure you get a copy of this policy and ask where this medical policy is located on their website. I tried to find it, but in my opinion their site is very generic. I do see that BCN has several Centers of Excellence for Bariatric Surgery, but not the procedures that it covers.

    Take a deep breathe and keep the faith!

    Hugs,

    JoAnne

  20. Posted

    I completed my 3 month supervised diet last week (7 months of WW documented last year, but had a 4 week gap, thus the need to complete another 3 months :cool: - insurance requires one 6 month or two 3 month supervised diets, within the last 2 years).

    I have my: Cardiology Clearance letter, Colonoscopy report, Mamo & PAP report, Letter of Medical Necessity, DEXA scan, Psychological evaluation, Split sleep study (come to find out I have mild sleep apnea) and my EGD was done today.

    This afternoon I received a call informing me that my paperwork has been turned over for submission to my insurance company. YIPPIE! :lol0:

    I?m so excited to be one more step closer. Hopefully, I will receive approval in the next few weeks, then have a date scheduled. I would love to have the surgery in early November in order to have a jumpstart into the new year!

    Best of luck to all scheduled next week. I?ll be thinking about you. Can?t wait till I become a ?sleeve sista?!

    Hugs,

    JoAnne

  21. Posted

    Here’s something my dietician provided me for the pre-op diet, the basic and alternative if you can’t do all liquid.

    The Diet:

    1. Drink at least 64 ounces of fluids per day (all must be sugar-free, calorie free, and non-carbonated)

    2. One multi-Vitamin with essential minerals per day.

    3. Consume 1000 - 1200 mg of Calcium per day

    4. No Alcoholic beverages

    5. Drink 4 - 6 no sugar added Meal Replacement shakes each day (recommends Adkins Advantage even though it has 1 gram of sugar. They taste great and have 15 grams of Protein and 24 essential nutrients plus Calcium and no trans fats)

    Sample Day:

    Breakfast: 1 shake

    Lunch: 1 shake

    4pm: 1 Shake (optional)

    Dinner: 1 Shake

    Bedtime: 1 Shake (optional)

    What if you break the liquid fast or just cannot follow a liquid diet for 2 weeks?

    Plan B - A shake and food meal plan that will keep the fat extremely low. The goal is still to lose as much weight as possible before surgery.

    The Meal Plan:

    2-4 8-11 ounce high Protein Shakes a day

    1 meal a day, composed of

    3 oz seafood, turkey or chicken (no skin)

    Or

    1 cup Non-fat/low-fat yogurt, cottage cheese or ricotta cheese

    And

    Non-starchy vegetables - up to one cup

    No corn, peas, potatoes, sweet potatoes or baked Beans

    Fresh fruit - 1 piece (1 cup) per day

    Olive oil - 1 tablespoon a day, no salad dressing, no Mayonnaise

    Eat only 1 meal a day. Limited to 20 minutes per meal.

    Sample Day 1:

    Breakfast: 1 Shake

    Lunch: 1 Shake

    Dinner: Stir-fry

    3 oz chicken

    ? cup broccoli

    ? cup mushrooms

    1 tbsp Mrs. Dash 10-minute Mesquite Marinade

    1 tbsp Olive oil

    Snack: 1 Shake

    Sample Day 2:

    Breakfast: 1 cup 2% Cottage Cheese

    1 cup fresh peaches

    1 cup Lettuce

    Lunch: 1 Shake

    Dinner: 1 Shake

    Snack: 1 Shake

    Sample Day 3:

    Breakfast: 1 Shake

    Lunch: 3 oz shrimp

    Lettuce

    1 cup zucchini

    1 tbsp Olive Oil

    Salsa

    1 Pear

    Dinner: 1 Shake

    Snack: 1 Shake

    Hope this gives you some alternatives.

    Hugs,

    JoAnne

  23. Posted

    I received this information from my dietician at the Center for Weight Management & Wellness. Hope you don't mind me sharing.

    ?Protein choice should provide at least 10 grams of Protein in 4oz of liquid.

    Whey protein is the best protein for fat loss during energy-restricted diets, when combined with exercise. Quality whey protein isolate has benefits including providing intact immunoglobulins to support immune function, providing the highest concentration of BCAA?s (branched chain amino acids leucine, isoleucine, and valine which play a key role in the muscle building process-about 25%). It also has a high BV (biological value) which means it is readily absorbed and utilized by human muscle tissue.

    BUYER BEWARE: Another ?low quality? ingredient popping up in Protein drinks, bars and bullets is hydrolyzed collagen protein, also known as Gelatin. This is an incomplete protein that is really cheap. If this protein is in the protein blend of your shake, I would be cautious especially if it?s one of the main sources of protein. Hydrolyzed collagen does have some benefits in terms of joint and skin health but not much for building quality muscle. Do not buy New Whey Liquid Protein bullets or protein shots.?

    Hugs,

    JoAnne

  24. Posted

    Thanks to all for your insightful input. You have reminded me why I chose the sleeve in the first place. I need to make up a cheat sheet of all the Pros, and pull it out whenever the "scared" feelings stir.

    I really am up for the challenges and lifestyle changes required to make the sleeve successful. In the past 2 months, I have replaced all soda with water/crystal light. Huge accomplishment for a diet soda junkie of 30 years!

    Hopefully in the next 6 - 8 weeks I will have completed all the requirements, received approval from insurance, and have a surgery date.

    Again, thanks for taking the time to respond to me and I look forward to sharing my journey with you.

    Hugs,

    JoAnne

  25. Posted

    My story is similar to many out here. I?m 53 and have fought weight issues my entire life. Childhood through high school was hell. The summer before college, I lost a lot of weight and started my freshmen year looking ?normal?. I was able to maintain the ?normal? range for several years, then began the yo-yoing after marriage. Had 2 children, and then this wonder drug called Fen Phen became a hot item. Again, I became semi-normal, until the risks outweighed the benefits. Since that time, I have gained over 85 lbs and just can?t seem to loose it.

    Several years ago, I started looking into WLS, specifically the band. After doing the research on the band, and following several individual blogs and forums, I knew the band was not for me. Earlier this year, while cruising the WLS boards, I stumbled on the Sleeve. This option looked encouraging to me and I started the research. I felt like my prayers had been answered. Additionally, I had gained more weight and reached the BMI required by my insurance company for WLS without requiring other medical conditions. I found a highly qualified surgeon who has an excellent pre and post surgery program, and have begun the clearance process.

    To date, I have been blessed and everything has been falling into place. My PCP fully supports me. The psychiatrist and cardiologist I went to also support my decision for WLS. So what is my problem? I?m scared to death that I will fail again even with the sleeve. I know that the sleeve is only a tool, and I will have to do the work required to make this successful. But what if I fail like I have so many times before? Honestly, I?m not trying to set myself up for failure. I?m just scared in getting my hopes up for ever being a ?normal? weight (not to be confused with the Hollywood standard). Looking at the accomplishments of MacMadam, Wasa and others, I feel I can?t go wrong. But then, I?ve said that every time I?ve started some sort of weight loss program.

    Is this paranoia to be expected? Any words of wisdom from those that have been there done that?

    Thanks in advance for your kind words and support.

    Hugs,

    JoAnne

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