Kat Crowder

Hi - I just was approved, and currently weigh 195. I'm not sure when my surgery date will be, but I think this is a great group for Louisiana Girl to have started, I hope it gains some traction. -Kat

Congrats! I got my approval today, too, but I don't get to talk through timing until tomorrow. My practice requires insurance approval before some nebulous "next steps", so I've no idea what I'm looking at time wise.

Unfortunately, my recommendation for tonight is to drink lots of fluids, and tough it out until you can talk to the practice tomorrow. I haven't gone through it yet myself, but it sounds like everyone's medical practice has different requirements, and you would absolutely hate to do something tonight that would affect your surgery date. :-/ -Kat

I just got approved today! Yay! I talked about this in another thread - I received a denial letter last week, primarily because the insurance coordinator for my surgeon's office hadn't submitted sufficient information (no information from my PCP except a letter, no information from my pulmonologist (and sleep apnea is my most advanced comorbidity), not enough info in the surgeon's attestation, etc.). I ended up talking to my PCP to get additional case information, sent medical records from my old doctor from 2001-2005 showing the comorbidities from back then, got my pulmonologist to supply a letter and my records, all to the surgeon's office. They faxed over ALL the records yesterday (I figured they'd go through and send the relevant ones, but no), and they set up a peer-to-peer talk between my surgeon and the insurance folks today, and voila, it's approved! The letter implied that an appeal needed to be filed, but when I called on Monday to ask if the additional documentation should be sent in an appeal, they said, oh, no, don't do that - an appeal can take up to 60 days or more, just send the additional documentation on the same case file. That wasn't clear at all. I bet it's really the peer-to-peer call that makes the difference to the doctors making the decisions - they don't want the explanation from Some Peon Without An MD and if they can get the information they need from a telephone conversation with someone with the letters after their name that they respect, they're willing to approve it. Another weird thing about my office is that they've refused to send me my "next steps" for after insurance approval until they had the approval in hand. So I get to find out tomorrow what I have left to do and what my timeline might be. I hope we can look at surgery dates. I believe I have an additional nutrition class, a GI exam, and some sort of preop diet to follow, but my pulmonologist has cleared me for surgery. I'm glad this is really happening! -Kat, who needs to work on a ticker for her sig at some point. :-D

It's thinking that I should be able to do it on my own and blaming myself for my failure that has kept me waiting this long to get surgery - keeping me depressed and unhealthy instead of taking the reins of my own life and doing what I need to do. I was so happy that my doctors were supportive, because I'd been so convinced that it would be cheating and taking the easy way out and that I should be ashamed of giving up on diet and exercise alone. Don't let other people do that to you - know that you're doing the right thing for you. It's sad when the people who care about you don't understand, and say things that are hurtful. Be strong. <3 And gramaof4, I feel obliged to say that what your husband is doing is perilously close to emotional abuse.

You're looking great!

Thanks, everyone - raindrop, I totally didn't mean to hijack your "yay, I'm approved!!" thread! I did call BCBS after the first submission to ask a question, and they responded to the submission with a request for more info, and all the office sent was a letter from my primary care physician, and the "attestation from the surgeon" that I've been properly educated. The denial letter came back saying that they still hadn't proven the medical necessity according to the guidelines and that they'd failed to submit the proper surgeon's attestation. That gives me little faith in the insurance department, because it's fairly straightforward to tell if you have a surgeon's attestation to certain things. I can see an honest difference of opinion between the insurance and my doctor as to whether sufficient other medical management of my comorbidities has been tried, but attesting to something is attesting to something. MinaT, I'll let you know how things go, and you do the same to me! -Kat

I am considering it as an option if I don't get approved for my surgery, but with a max $1500 out of pocket on my insurance, I'd rather have it done here and stay local. I don't see any information about there being an exception for the OOP maximum for bariatric surgery for BCBS IL, but I'll be sure to call them on Monday.

Yep, I do. However, the office insisted on putting me through with diabetes and sleep apnea as my two official comorbidities, when I told them I didn't have diabetes, I had prediabetes, and my comorbidities were sleep apnea and dyslipidemia. Also, they didn't bother getting supporting information from my regular doctors. So, I've been denied and they're going to appeal, and I've insisted on them getting all my medical records to prove things.

How awesome for you! I'm having a heck of a time with the insurance people at my surgeon's office.

Interesting thread - I looked up the BCBSNJ medical policy and it said the sleeve was only for BMI > 50, but if adrimc26 got approved with a BMI of 43, it looks like they're making exceptions.

I actually think it makes more sense than the other way around, which is often the case. This way, they're providing discounted care to people who have to self-pay, and charging more like the actual cost to the insurance companies. What I hate seeing is when something "costs" X dollars, but the insurance discount is huge because the insurance company has agreed on a price that's so low that self payers need to make up the difference. That happens a lot in laboratory testing, for example. $700 tests can cost the insurance company only $25, but if you aren't on insurance you need to pay the full price or try to negotiate it down.

I suggest finding out what your insurance company's medical policy on weight loss surgery is. It seems like most of the BCBS websites have Medical Policy under their "Providers" tab, and you can find what the specific requirements are. I think it's important to educate yourself straight from the source, and get all the information you can. I'm finding that I really need to guide my surgeon's insurance person to gather the right information to submit, which is frustrating, but I'm the person most invested in getting my insurance approved. Good luck!

I would be livid, too - The person in charge of insurance at my surgeon is crappy, as well. Here is the link to the medical policy for BCBSDE - since i have BCBSIL and have been spending a lot of time checking out medical policy, I figured I could find it in a similar place for you: https://www.bcbsde.com/ProviderPolicies/public_site/7.01.36_Obesity.htm It states: "The following procedures are covered for the surgical treatment of morbid obesity when all of the patient selection criteria are met. (other procedures deleted here) · Sleeve Gastrectomy (43775) For the superobese patient with a BMI of ≥ 50 who is 18 years of age or older, sleeve gastrectomy is an eligible procedure as a first stage of a two-stage procedure, or as a sole definitive procedure. A sleeve gastrectomy is an alternative approach to gastrectomy that can be performed on its own, or in combination with malabsorptive procedures (most commonly Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch). In this procedure, the greater curvature of the stomach is resected from the angle of His to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum, and avoiding the dumping syndrome (overly rapid transport of food through stomach into intestines) that is seen with distal gastrectomy. This procedure can be performed by an open or laparoscopic technique. Some surgeons have proposed this as the first in a two-stage procedure for very high-risk patients." And then below that it lists the patient selection criteria which you have been working to meet (besides already having the BMI with comorbidities). This policy could be read two ways. The 50 BMI information could be merely that - information about how the sleeve applies to 50 BMI patients, or it could be considered selection criteria. It doesn't exist in the patient selection criteria section, though, and I think that implies that it's informational. The descriptions of the other procedures don't provide any selection criteria. The insurance companies make it difficult for you to involve yourself in the insurance approval process, which is frustrating. BCBS-IL has a peer-to-peer line where your doctor can call to discuss the denial, but the surgeon doesn't want to deal with the insurance issues, that's theoretically what he pays his insurance staff to do. And they're not medical people, they're paperwork people. Did you get a denial letter, or is the office staff interpreting the medical policy? If it's the latter, I would completely argue the point. Print out the policy, highlight what's relevant, and explain that the sentence about 50 BMI patients explains what it is for 50 BMI patients, and doesn't exclude its use on others. I agree with reporting her, too. If you request to speak to the doctor, they have no right to refuse you.

I hope everything's gone well for you! Two days post op now?

My insurance ought to pay, too. They're just being annoying. They want your doctor to document medical necessity by listing 2 comorbidities that have not responded to maximum medical treatment, and when my doctor did that, they still denied it, because apparently she didn't justify it the way they wanted. It's not like they provide a form or anything. Why couldn't I have gone through this exercise while I was doing the 6 month supervised diet, worked out the kinks, and gotten conditional approval pending the diet program? Frustrating. I'm so ready now, and I'm annoyed by this stupid back and forth of documents. Gah.

There are a lot of factors that come into play when you're deciding on surgery. If it's not something covered by your insurance and you're not wealthy, you're going to look at cost as one of those factors. I think everyone would like to have the best outcome at the lowest price, and it's a matter of massaging all the data to decide what's best for you. Right now I'm not thrilled with my surgeon's insurance department - maybe that's something else you'd want to look at. Is the surgeon close to you, or if not, is there a doctor who can do followup appointments? How many surgeries has the doctor done and what were the outcomes? I would universally say to not look at price exclusively. You can definitely consider it, though. Make sure you know what that price includes, as well, and then figure out the cost of the needs not covered. Those are just my thoughts, having not yet done it. There's a surgical center that's a Bariatric Center of Excellence right near me, and my insurance covers them (although I just got a denial letter that I have to appeal), so I just need to cover my max out of pocket, hopefully. Good luck!

I spoke to my psychiatrist today, and she said that it was OK to dump the Effexor XR capsules out, and take them with whatever I can tolerate at the time (whether it's Clear liquids at the time, or so on). She said that especially with such big changes going on, it's important to stay on the anti-depressant meds, and I agree. Vivid or scary dreams are things I get if I miss a couple days of the Effexor XR, so I can see it being a potential side effect of the non-extended release, too. Yeah, you might get a little more nausea on a stomach without food - but I frequently take my pills with no food, or just with a Protein shake, and I'm used to it. Hopefully it won't hurt your sleeve enough to have to throw up, but I'm pretty sure you want to stay on it. Cheers, and good luck!

Another forum post says the surgeon recommended spilling the capsule into applesauce. I think I'm going to go in and talk to my psychiatrist about it.

I have my insurance preapproval submitted, I'm out in Lake Zurich, but still Chicagoland.

Awesome attitude - it's real, and it's for life, and the prep is going to mean a lot. It's not a delay, it's just part of the process.

I'm four months into my 6 months, and don't require the supervision any more so I'm moving forward. It was inconvenient to take a half day off work every month to go to the supervision visits. Furby, I'm surprised that you still require a 6 month supervision. If you go to the BCBSIL website, access the providers page, then go to medical policy and search for bariatric, the bariatric surgery policy doesn't require 6 month supervision. Is the 6 month supervision a special restriction put in place by your employer?