gina0922

I'm wondering if it's even worth putting in, our insurance changes from Aetna to United Health Care on 1/1/09..... I'm thinking they will just put me off till after they aren't our carrier any longer. Our company does have it's own dedicated perauthorization at Aetna so it may go smooth. I see my surgeon on 10/28 it will be a tight window.

TMBOWE - The Aetna website says there are two options for the prepreation 6 month monitored diet or a 3 month plan where you have to have psych eval, nutrition...etc did you have those options or did they tell you 3 month monitored diet?

I have the same issue in regards to the insurance changing. I currently have BCBSNJ which is changing to Aetna Jan 1st. I have done everything BCBS requested as well as what the Dr required. All my info/test results/documentation is with the Dr's insurance coordinator now. I am worried that my current insurance will try to stall me till it runs out. I have read where that is illegal for them to do that though. I have a 47.5 bmi and more co-morbidities than I want to even think about. If I am denied it will only be due to something someone forgot to include because I have done it ALL!!! Psyche, nutritionist, cardiac clearance after Angiogram, h pylori test, blood work, gall bladder ultra sound & chest xray. I even did an extra (7 in all) months of monitored diet just so they couldn't say I didn't have enough days in.

One more thing I worry about (as if there weren't enough) is that I never had a regimented exercise program. I did what I could but w/COPD walking is pretty difficult at this weight. I do use my hand weights and my resistance band. Much of the exercise is in a chair. But it's moving. I can't afford a gym membership. I read Aetna required a supervised exercise program. Is that true? What's more is I don't even know if my employer chose to include or exclude wls in the new policy. They had it worded as "Medically Necessary" in the current one. Hopefully they have carried that over.

If you have any suggestions or information, I would really appreciate it!

I am soooo nervous! My insurance is changing from BCBSNJ to Aetna Jan 1st. and who knows if it will be included or an exclusion in the new policy.

I get the results from my cardiac clearance on Monday. Then everything that has not been submitted to the surgeon will be hopefully by the end of next week. Anyone know how long it takes the surgeons office to submit to the insurance? What is the "dictation" portion I have read about?

bumping this post...hoping to get an answer from someone

I am soooo nervous! My insurance is changing from BCBSNJ to Aetna Jan 1st. and who knows if it will be included or an exclusion in the new policy.

I get the results from my cardiac clearance on Monday. Then everything that has not been submitted to the surgeon will be hopefully by the end of next week. Anyone know how long it takes the surgeons office to submit to the insurance? What is the "dictation" portion I have read about?

So, Gina did you get your band?? I was banded on 9/2 by Dr. Domkowski at PBCH... I live in Melbourne, but work at the hospital (PBCH). It has been the best thing I have ever done for myself. I hope all has worked out for you...

I didn't know that there was another Dr here in Palm Bay that did the LapBand other than Dr Fusco. Wow, I will pass that along to a lady I work with. She wants to have the LapBand but doesn't want to drive to Ocala. Did he have a huge program fee like Fusco?

I just drove by PBCH yesterday for the first time since they broke ground for the addition. Wow! That's gonna be a really big hospital when it's all done. But they really did need it. I prefer PBCH over Holmes. I feel like I am just an Insurance # at Holmes. PBCH nurses were always so nice and friendly.

I have decided to go with RNY. I have (hopefully) one last thing to conquer and that is an ECG and a stress test. I am now finishing up with a 10 course for H Pylori. One more blood test for that too. Then everything goes to the surgeon and off to BCBS. I had my consult w/the WLS 08/29 and at that point he was booked till mid to late Oct. So if I get a quick approval I am hoping to get a surgery date of early to mid Nov.

How are you doing since the surgery? I hope everything is going well for you. Do you go to the Melbourne support group? It is for anyone pre or post wls. The next meeting is on 10/06 at the food court in the Melbourne Mall @ 6pm. I am planning on attending for a while. It will be my first group meeting. If you do decide to go you just have to look for a red headed woman with a green purse. :biggrin: Hope to see you.

she didn't listen and was so confusing. I told her several times that I have hypertension and that my insurance may approve it based on my record of being at 38% BMI and she kept asking for records of being 40%. I don't have them. She also kept telling me that my ins said I need two comorbidities and she even called the ins and they said 'no, just one' and when she hung up, she kept asking me what the other comorbidity was. She also told me I need to show two years of records. I have stuff from 2005 (and earlier), 2007 and 2008. She said I will get rejected because I need 2006, 2007 and 2008. Finally, she told me to not take my meds for hypertension as "controlled" hypertension isn't a co-morbidity and it clearly says on the web site that it is. I am just absolutely freaked out she will screw this up. Should I trust her or have the surgeon "speak to her about my file".

Is she insane? :thumbup: Is she even hinting to you that you should stop taking your BP med? The reason for the surgery to to eliminate the need for the BP meds due to weight loss that comes from the surgery. That is like saying well you need to have a comorbidity like type 2 diabetes to be approved for surgery but if the med's your taking for the diabetes is controlling it, then you won't be approved because of the med's or insulin, you have normal blood sugar readings. What the hell is she talking about?? You really need to speak to the surgeon about that. She could cause someone some serious medical problems if they were to stop taking a needed prescription. :thumbup:

I just don't sleep well but I don't stop breathing while I am sleeping. Insurance bmi terms are 40% or 35 if medical problems.

I didn't think I stopped breathing either. Not until my sleep test. I thought I was sleeping soundly. I found out when I went to my PCP for my next monthly weigh in that my results showed that I had right at 50 events an hour. :smile2: So you really never know till you take the sleep test.

But I have to say that since I have started using the CPAP machine, it has made a world of difference in how I feel during my waking hours. I'm not falling asleep at work now or even when I stop at a red light! :tt2:

It's was a breeze for me! My psych required 4 visits over 4 weeks. They mainly consisted of her asking me a lot of questions regarding my life from as early as I can remember to present. What were my reasons for having the surgery. What type of support structure did I have in place after the surgery...blah...blah...blah. I answered honestly and it was all easy. I actually liked my sessions with her and may go ahead and keep going maybe once a month. My insurance pays for 20 visits a year.

You'll be fine. Just be honest...they are trained to know when you are BS'ing them. Remember, they take notes and you may forget what you told them and if you lie they can catch you and may not approve you. I wouldn't want to take that chance.

I was approved a week or two ago!

My surgery is Sept 22! Im so excited!

Time will fly for you all! Best of luck!

CONGRATS!!!!!!!!! Sept 22 is my birthday! I will give you my birthday wish :biggrin: Wish for anything you like! LOL

Gina - you show that you are in Palm Bay. Dr Fusco is in Melbourne close to Holmes. He did mine & I'm delighted.

Going to Ocala for fills is going to be trying.

I went to Fusco's seminar. When he through that $3700 "Program Fee" out there I knew he wasn't for me. I just don't have that kind of cash laying around and I can't see getting an equity loan for it either. Besides, per my Insurance I have to go to a "Center of Excellence" for my ins to pay "In-network" amounts. And the closest one is Dr. Jawad in Ocala, he also does lap band and he includes the cost of the fills in the surgical fee, so that the ins will cover it. He has no program fee either. Only a $250 consultation fee. My surgery will be there but my follow ups will be in Orlando. After the initial post op visit, I will only have to go every 6 months. For me the drive was worth saving the $$ that Fusco charges. I hear he is a good Bariatric Surgeon, I just couldn't afford him.

I also decided that GBP was a better option for me after talking to my PCP. I have read many positive and many negative things about both surgeries, but for me, having to continually get the fills was just not something I wanted to do. I need the restriction all the time, because I know me. I would just say, "Well maybe I'll go next week for a fill". Something would happen and I would put it off. So a GBS is my choice.

Best of luck to you!! How much have you lost?

I went to a seminar of his and he was really pro RNY. I got the impression he didn't like Lap Band very much. I have since picked out a surgeon in Gainesville. He is listed on the lap band website as having done the most lap band surgies in the area though.

I think he does prefer the RNY over the Band and he has done over a thousand of them and somewhere around 500 or so of the Lap Band surgeries. But as far as a bariatric surgeon, from what I have read and believe me I have done a lot of it, Dr. Jawad is rated #3 in the nation. Either way I think you would be in good hands.

But if you found a WLS that you are happy with then you have made the best choice for you and that is what is the most important thing.

Where are you in your process? Do you have a surgery date yet? I go to Dr. Jawad for my consult on 08/29. I have almost all of my pre surgery testing done. Last thing is my last weigh in on Sept 8th and my final psych visit 09/02. Then it off to the ins for approval. Whew! It's been a long 6 months!

I did my 6 month diet with my PCP before I went to my surgeon because I knew that it was required. if you have not done that yet then I am sure you will have to wait. I was not sure what surgeon I wanted to use so during that time is when I did my 6 months as well as my psych and nutritional evaluation so that when I finally picked a surgeon I had everything all set

Jetti,

I am right there with you about getting it all done before seeing the surgeon. I will have my last psych appt on 09/02 and the last weigh in at the dr for my 6 month diet on 09/08. My appt w/the wls is on 08/29. I wanted to be completely done but the next appt available was around the third week in September and I didn't want to wait that long. I will take my results from my mamogram, sleep apnea test, pulminologist, gall bladder ultrasound and referral from my pcp with me and just send the rest when it's done and ready. I am so ready to get approved and get my surgery date!

The insurance coordinator just emailed me to let me know I'm approved! I am so damn happy right now I can't tell you. After being on edge for a few days this is such a relief. So I didn't technically have 6 months of dr. supervised weight loss, I had 6 visists once a month for 6 months(first visit was feb 28th last was july 28th) But I did have 6 months of dieticians notes and all the other stuff was well documented. Man I am glad I saw a dr once a year for the last 5 years! What an arduous procees I'm glad the waiting is over!

Hi, my doctor wants me to stay on the 6 mo diet one more month because I actually gained weight (8 lbs) and although we discussed weight loss, she did not put in her notes (in my file) that we discussed WLS in March but did in April. Will this matter? I had my 1st consultation about weight loss with her in March. I have gone each month. I am like you in that I have had 6 documented of monthly weigh ins (03/07, 04/09, 05/07, 06/09, 07/09, 08/08). If we add one more month and show the start date of 04/09 and then weigh again 09/08 will I have to wait till Oct for it to be considered a 6 month supervised diet? I just don't want to have to go through an appeal process because of 1 extra weigh in. I have BCBS and they didn't require a 5 yr history.

From what I have read, the standard rule of the whole 6 mo Dr supervised diet thing has been for the most part, ongoing monthly Dr appointments where you see the Dr, get weighed in and talk about how your weight loss is going. My Dr just had me follow a reduced calorie diet. My insurance which is BCBS of NJ just stated I had to lose or maintain my weight during the 6 months. Doesn't matter if you talk about other things, heck, your at the dr's office, it would be silly not to talk about your bad back at the same time. But you have an individual policy so I'm not sure how they would rule on that. Best of luck to you!

Ahem...well, many of you are talking about being able to be on top again. I am looking forward to just having sex again. Because of my weight and subsequent lack of self esteem I have not had sex with my husband going on on 2 years. Luckily, God blessed me with a totally loving and understanding husband. I assume he is taking care of business himself. I am sure that he would not care but I cant stand the thought of it at my weight. It affects my breathing to have all the weight pushed down on me (hubby isn't exactly a small guy) as I have breathing problems (COPD). Knees are shot so I can't do it doggy style. Can't get on top and fold my legs under me like I am sitting on the fronts of my legs because of all the swelling in my lower legs.

So you can see that I am really looking forward to having the surgery. I don't care what position it is as long as I get some!!!!!

Ok, I finally called my insurance comp, BCBSNJ and was told it was "excluded unless it was medically necessary". She told me I needed a predetermination letter by my PCP. I have a 48.1 BMI with several comorbidities including Type 2 Diabetes. The medically necessary part is definitely there. What worries me is the "excluded unless it was medically necessary" part. I have read all around my insurance book. I didn't see anything about WLS. Even in the exclusions section.

Has anyone come across this situation or verbiage in your insurance book? If so, were you approved?

Thanks,

Gina

I have Horizon BC/BS of NJ and it took 1 week after completing all the criteria. I got mine today!!!! YES!!!

I have BCBSNJ too but I live in FL. What did they require of you to approve you for the WLS?

Congratulations!!

Gina

Hey Gina,

Surgery went well, I was back home at 6:30last night. Did some walking around the house (blood clots) drank my liquids, went to bed and slept until 4:30 this morning. Now Im pretty much awake for a while, but not a bit hungry.! Was wondering what that"other" RNY thing is? do not think I heard of it. Just keep pluging away and each day that goes by is just another day you don't have to wait. Take care and keep me posted Gail

Hi, just wanted to check in with you to see how your doing? How much weight is gone? Have you had your first fill yet? OMG so many questions!!

Gina

I see the Dr tomorrow which will be the end of my 3rd month. I really will be glad when it's over and done though!

Gina

Hi, does anyone have a good example of a predetermination letter that I can use that would cover either the LapBand or the RNY bypass? I go to the Dr on Wed as part of my 6 mo Dr supervised program and I would like to go ahead and have her fill out one so I can submit it to my ins. I have to find out what is covered if anything before I go any further. I am an emotional wreck over this. The more I read about these surgeries the more I want to just throw my hands up in the air and say "FORGET IT"!!!!!! So if you have one and could email it to me I would be most appreciative.

gina0922@cfl.rr.com

Hi everyone! Since my last post I have done some leg work on this exclusion in my policy. I was told to contact my HR director at work and speak to her. I really didn't want to go this route since I was trying to keep it private. She is a really nice and helpful person and I knew I could talk too her. I explained what was going on and she said she would put me in touch with the broker who my employer goes through for health insurance. I had to wait the entire weekend which felt like an eternity! On Monday, the rep called me and we went over EVERYTHING I was told and all my diagnosis's. She told me she would look into it and get back too me. Today, Tuesday, I called her to see what the status was and she said they are still checking into things. I am keeping my fingers crossed and saying my prayers that this comes back with something positive. I was told by the doctors office that sometimes employers have been know to remove that particular exclusion from the policy. I have been with the company for over 17 years and have good relationships with the owners and management. I really need to get this for so many reasons but the most important one is for my health. I have high blood pressure, a BMI of 44, onset diabetes and sleep apnea! What the hell more do they need? Gotta love Horizon BC/BS! Maybe I actually will!

Hi Dee,

I will definitely have to keep up with your journey with Horizon BCBSNJ as I have them as my carrier also. I spoke with a rep from the ins comp myself and was told it was excluded unless it is medically necessary. I called my HR person because I wanted to know exactly what the insurance would require of me such as the 6 mo Dr supervised diet (secretly hoping they would say, "No that is not required") before I paid out any money.

I got the email yesterday that the CPT codes (Band and RNY) I sent her were not covered. But I should have my DR to send in a pre determination letter to verify. So now I don't know which way to turn either. I requested an insurance booklet from her today. I want to see where it say that. Is there a difference between "Not Covered vs Exclusion or Excluded" Because she definitely said unless it is medically necessary.

But then again, they told you that 3 times.

Hey Gina,

Surgery went well, I was back home at 6:30last night. Did some walking around the house (blood clots) drank my liquids, went to bed and slept until 4:30 this morning. Now Im pretty much awake for a while, but not a bit hungry.! Was wondering what that"other" RNY thing is? do not think I heard of it. Just keep pluging away and each day that goes by is just another day you don't have to wait. Take care and keep me posted Gail

Woo Hoo!!! Congratulations! You're on your way now!

The RNY I mentioned is the Laproscopic Gastric Bypass. Who did your surgery? Dr. Fusco in Melbourne? I just couldn't go with his $3700 program fee. Dr. Jawad only had a $250 consultation fee. That's more in my budget!

LOL

Well Sweetie...good luck to you!! Keep me up on how you are doing.

Hugs,

Gina

good morning Gina, just checking in to see how you are doing and if you went over to Ocala yet to check on any of your BAND stuff there. let me know how you are moving a long. Gail from T'ville

Hi Gail,

I see you are getting the band today! Congratulations!!!! I went to the seminar Dr Jawad had in Kissimmee. It was very informative. I am still up in the air over having Lap Band or RNY. When I spoke to the Dr he said he felt I would be a better candidate for the RNY. I have to go to the Dr on the 7th. I will be starting my 3rd month of the Dr supervised diet. At that time I will ask her about the Psych and Nutritionist referrals. Might as well get them out of the way too. By the time I get ready to see the surgeon I should have all the paperwork in hand for him to submit to the insurance. I hope it's not all for nothing.

Well let me know how you are doing and how the surgery went. God Bless!

Hugs!!

Gina

My heart goes out to you. I am still pre-op and undecided if I will choose LBS or RNY. So I cant give you any advice as to this phase you are going through. I can only say I am sending you a great big {{{{{HUG}}}}}

Stay strong and remember that the ones who love you will always be there in your corner. They will understand that this is something you are going through and this is not your normal behavior. They will be there when you come out of this and their arms will still be open wide for you!

Hugs!

Gina

msm1961

Hey Im from middle tn we have a meeting every 2 Monday in the Murfreesboro @ Bodywise @ 6:00. And in Shelbyville @ Fair Haven Baptist Church the 3rd Monday @ 7:00. If you need more information pm and I will tell you more about it.

Kim

Hi Kim,

I'm from Shelbyville too but I'm currently living in Melbourne, Fl. I lived in Shelbyville for 23 yrs. You know you really are from Shelbyville when you start calling it "Shebvull"! LOL Well, I actually lived outside Shelbyville in Petersburg for my last 8 yrs in Tennessee. My daughter still lives in Shelbyville with her husband. I would move back in a heart beat too! Florida is a great place to visit but that's about it to me.

I am at the beginning of my 6 mo diet. Hopefully will be banded in Sept.

I just wanted to say hello, best of luck to you!

Gina

Hi I'm looking for anyone in the Space Coast area from Titusville down to Melbourne who has had LBS. If so, when and who was your WLS? I am just starting the process and would enjoy reading or possibly even chatting with you about your experiences so far?

Thanks,

Gina