brittu

Hi, Well my 14 month appeal is over - I lost. Now I finally got to do what I should have done months ago: schedule my surgery. I'm all set for surgery on the 29th with Dr. Aceves. For those of you who had surgery in Mexico can you give me a little advice on what to take and what to do (and not do) while I'm there? I thought there were posts on that but couldn't find any. I'll do a bit more searching while waiting for your replies :-). First off, I'm planning to fly first class home. San Diego is about a 3 hour flight to Seattle and I thought it would be nice to have lounge privileges while I wait and a bigger more comfy seat. Does that makes sense? My husband thinks I'm crazy. Will I be able to drive myself home from the airport? My flight down is at 6am so it'd be much easier to drive. I'd think I could drive home 3 days after surgery but I'm not sure. Do I need my laptop? Or can I live just fine with my iPhone and Kindle? Is it a standard 120v plug for recharging? Am I ok to go alone? I figured it'd be fine and that in some ways an extra person could be a bother when I just want to rest. How long do I get IV meds? I have survived some pretty painful surgeries but had a rough time with my lap band. I'd like to be as pain-free as possible. What all should I take? I was planning on reading materials and my phone. Two sets of clothes for down and back and comfy PJs for my time there. Normal toiletries like toothbrush, shampoo, etc. What am I missing? Do I need a hairdryer? Do I need to take Protein with me? Or is that all taken care of? That's all I can think of for now. I'm sure I'll think of more as soon as I press "post"... Thanks! Britt

Thanks everyone, for your good input. I'm hoping the attorney will call me with news one way or the other and I can move ahead. I've left another message for them today. ouroborous, how did you reconcile the risk of complications? I wanted to have my surgery with Dr. Billing at the same clinic you went to but Amber (their insurance person) tells me that complications aren't covered. Even if I could get a reasonable price for the surgery, I just can't risk catastrophic costs if I had a leak or other serious complication. Britt

So I'm thinking about giving up on my insurance fight and just switching to self-pay. I had a slipped band over a year ago. It took 6 months to get the insurance company (Fed BCBS) to finally agree to remove the band but they denied a revision to VSG stating it wasn't medically necessary because my BMI was under 35. I submitted an appeal to the Federal Office of Personnel Management in October for what was supposed to be a 60 day appeal. They "lost" my case and had to start over. Then they closed it because they didn't understand I was asking for a revision and not some sort of random partial gastrectomy. They finally sent it out for review but it sounds like they didn't select a bariatric surgeon because the answer last week came back that it isn't medically necessary because my weight isn't over a 40 BMI. The told my attorney to wait for the report and then call and talk to the nurse but I haven't heard back yet. At this point it's been almost 7 months since I submitted the appeal. This has been going on for so long I'm almost back to my original weight. If I had it to do over again I'd have done a self-pay revision with Dr. Aceves right from the start. Heck, I'd be at my goal weight by now. I just don't have it in me to keep this up. I went ahead and requested a surgery date with Dr. Aceves and put first-class airline tickets on hold on my miles. I can't think what hoops the insurance company would have next. They just don't get that the standard of care for a revision doesn't require you to regain all your weight first. I could go forward with the surgery and then sue them after the fact but I'm not sure it's worth the mental energy after all this. I had some old Microsoft stock lying around and it's almost enough for the surgery. I'm thinking that I'll never miss the money and can just get on with my life. I don't want to self-pay up here because it's really expensive and they don't cover complications like Dr. Aceves does. I could be down there next weekend having this done and just moving on. Thoughts? I could use some additional input... Thanks! Britt

My insurance paid for it (Federal BCBS) although they fought me on it. Mostly they fought because I wanted a revision to a different kind of surgery. But eventually I won and they weren't the original insurers. Britt

It's not quite the same but I got a denial for lap band removal (mine slipped) within 5 days. I appealed and it took 9 months for them to approve removing the band. Then it's been another 7 months since I appealed to Washington DC for a revision. Appeals are supposed to be closed within 60 days. So in my experience they've been super fast on the denials and criminally negligent on the appeals. Britt

Sorry you have to go through this, Bernadette. It's so hard when you have an experience that brings you around to the truth that most human beings put themselves first and that true loyalty doesn't really exist when it comes to the workplace. I spent 13 years at a certain software company just south of where we live (I'm in Mill Creek too) and was asked to take a poor performance score to balance out the curve for everyone else because I was part time and had had great reviews and bonuses up until that time. They felt I could be loyal by "taking one for the team". Well my answer was "see ya" and I "retired". I've come back on my own terms as a consultant free from all that - able to work when I want and say what I think without worrying about it's impact on my "permanent record". Making that change freed me up for a lot of new things in life. I'm now thinking about expaning my business and adding some new ventures. I never, ever thought I'd have the energy or confidence for being self-employed and now I'm wondering why I didn't make the change long ago. I don't want to be bound by other people's perception of me or their silly workplace culture. All I'm saying, in long-winded fashion, is that life takes you places you don't expect. Taking the bumps as opportunities to learn who you are and kind of throw off what other people tell you to be can be exhilirating - especially at this time in our lives (I'm only a few years behind you). I'm rooting for you and whatever you decide is next. Britt

I'm still fighting. I hired the Lindstroms at Obesity Law to represent me on this final round that bounced my case from the local Regence office back to Washington DC. There has been one delay after another (the DC office seems to have lost my case and has had to start over). At this rate, 1 year since my slip, my weight has gone up so much I'll be back at the original qualification for non-revision WLS in no time (she says with grim irony). I am not feeling hopeful that I'll win. I did prevail on band removal, that's out, but I need the VSG. I'm disappearing again under a layer of fat. It makes me too sad to talk about really. One way or the other I hope it'll be over soon and I'll know whether they're paying for the surgery or I am. Best of luck to you. I'm glad to have the band out, after it slipped I was in pain for months on end while I fought to get it out. I strongly recommend the Lindstrom's, they've been amazing. Just having someone fight for me after fighting the first two rounds myself was worth the money. And frankly, I think they have incredibly reasonable rates. Take care, Britt

Well my advice is to keep fighting and go for the appeal. The BCBS plan statement actually has to be administered uniformly across the country but some local companies doing the administration (like Regence here in Washington) are disregarding the benefit guidelines and denying it. I had a slipped lapband and was told that VSG and band removal are both covered. VSG is supposed to have been allowed as a gastric restrictive procedure by Fed BCBS as of January 1st 2008. (My lap band was originally covered by my insurance because I met the >35BMI + 2 comorbidity requirements.) Even after both the doctor and I were told the revision would be covered, the local Regence office sent a denial letter. They appear to know nothing about weightloss surgery or the lap band, much less the VSG -- they were so far in the weeds they actually denied removing the band and claimed they couldn't remove it because my BMI wasn't high enough any more (huh?). And they denied the VSG revision under the investigational claim. They even denied letting me have it unfilled so we could get the pain and vomiting under control. They said fills are only covered when your BMI is over 35 too. That's going to be news to lap band patients everywhere - don't bother contuing to use your band once you lose some of your weight. That was such a stupid thing for them to do all I could do was laugh about it. They backed off that pretty quick, after hassling me about it they suddently stopped mentioning it and just paid the claim. I ended up appealing. For the first round of my appeal I wrote my own letter and won the band removal portion only but they denied the VSG again. They dropped the investigational reason and their denial to being because I don't qualify for weightloss surgery with a <35 BMI. Since I did qualify for the original lap band surgery that's kind of dumb. The standard of care with revisions is not to treat the revision as if you're starting over pre-WLS so it makes no sense. You don't give someone a knee replacement and then when it breaks and the doctor needs to replace it with a different type of artificial knee that the patient is out of luck - you only get one shot a knee replacement. My BMI is back up to 33 so they won't have to wait long until I qualify again . Although the surgeon and I wanted to do the removal and revison in a single procedure, I went ahead and just had the lap band out in October. The insurance company gave me four weeks to have it out from the date of their appeal decision so I just needed to get it done. And I was miserable. I can't believe anyone would force me to keep a slipped lap band in for over 7 months - that's crazy. It's great not to be in so much pain. But it's scary to no longer have any kind of restriction. I went ahead and hired Walter and Kelley Lindstrom to handle the appeal from here. Well worth the money just to have someone fighting for me after going it alone for so many months. We'll see what happens, I should know what the Office of Personnel Managment in D.C. wants to do next in a couple of weeks. I'm going to take it all the way to the end to make sure this gets their attention - that some state administrators are making up their own rules that go against the benefit statement. I posted the letter and addendum I used for my first appeal in case it's useful to anyone else. All I know is that it did seem to get them off the investigational part of the denial. Best of luck! Britt vsgappeal: Appeal Letter

I was thinking about a leak or infection that's not detected during the initial hospital stay. Or some other related stomach complication like cancer or reflux - anything that the insurance company could claim was related to the partial gastrectomy and therefore not covered. Usually I have the will to fight. But I just want the band out. I called Dr. Cirangle's business office today to find out what my portion of the cost of revision would be if the lap band removal was covered. I think that'll determine a lot about what I'm willing to wait for vs. what I'm willing to pay for. I'm at the point where $11k feels easier to come by that creating more paperwork and wading through two more rounds of appeal... Especially since I have confidence in Dr. Aceves and also feel better knowing that I'd be under care for 3 days after surgery and not just sent home asap. Even though I'm only 25 pounds away from the BMI requirement I just can't gain that weight again. It's not worth the money. I had to fight a bit to get the lap band covered the first time around with a different insurer, they didn't agree that my comorbidities justified the band. So my BMI went up from 35 to 38 while I battled it out. It was so demoralizing and it seemed so stupid - the general implied advice that if I just gained more weight my surgery would be covered without question. I definitely appreciate everyone's input. The sleeve seems like exactly what I hoped the band would be. I'm just more cautious this time around. And scared I guess that even if the VSG feels better what if it doesn't help me lose more weight. I wish this all wasn't so hard! Thanks, Britt

Thanks Wasa, your input is really helpful! Unless I gain another 30 pounds Fed BCBS isn't going to budge on fixing this. I got their appeal acceptance and they totally threw down the gauntlet to make sure I knew that the 35 BMI was non-negotiable. I'm guessing I will eventually win having them take the band out but that won't help much since my doctor here does explant and vsg as two separate surgeries six weeks apart. And I can't seem to find anyone except for Dr. Cirangle who'd do it all at once and just charge me for the additional procedure cost. But I understand that he has an $8k post-op program which would put me back up higher than just scheduling with Dr. Aceves in the first place. I need to check on that but Dr. Cirangle's business office never returned my calls or emails after I had a consult with him and my first conversation with the coordinator. I completely trust Dr. Aceves and would be happy to go to him. But I would worry about some future complication that the insurance company would refuse to cover. Ah, why does it have to be so hard. What I meant by the VSG can't be undone is that if a few years from now some complication occurs my stomach can't be restored. I don't know what problem could come up, it's just that I'm a little more cautious this time around. Thanks again! Britt

So I have a band that worked great for 18 months. Then I stopped losing weight and found out this winter that I had a dilated pouch and probably a small slip. I'm fighting the insurance company who doesn't want to take it out or revise to a VSG. I suspect I'm going to end up being self-pay after months of angst but that's another story. I was in la-la land with the band for the first two years. It was working so I just ignored how unpleasant it was. Sliming and vomiting. Heartburn. The contant feeling of swelling. Even on a fairly good week eating solid foods isn't that pleasant. I can always feel the food sit waiting to make it through the stoma. I'm never sure if it's going to get through or not. I can't lay down after eating. Mostly if I'm eating healthy food I'm thinking about trying to avoid discomfort. I don't think I really feel full like I expected. I should have clued in when the surgeon warned me that I'd have to learn the new signs for being full with the band. I thought I'd feel satisfied after eating. Sometimes I do, sometimes I can eat more and don't. Sometimes I'm in pain and vomiting not knowing when whatever is stuck in there will make it down. The sleeve is a serious choice. It can't be undone and if I'm self-pay I'm taking a big financial risk. I thought I did my research on the band but I didn't pay too much attention to the side effects. Like everyone I assumed it would never happen to me. The idea of having to be uncomfortable when eating for the rest of my life - I'm not sure if that's something I can live with, even if I get to a good and healthy weight that I can maintain. I know that foamies, pain with overeating, and other things can happen with the sleeve. But what does it feel like on a day to day basis? How much of the standard discomfort I feel with the band will I feel with a sleeve? Will I feel food sitting around? Or food kind of up in my throat? How about the feeling of pressure or the near-constant feeling of swelling or inflammation? I just want to know what I can realistically expect my life to be like if I woman-up and go for it :-). Thanks, Britt

Well hang in there, my fingers are crossed for you. Someone replied on one of my threads that they finally had success with appeal 3 when they hired an attorney to help and won. They hired Walter and Kelley Lindstrom and it sounded like their written appeal was so effective it just turned the tide. The blog posting I got good information from was from Teresa at ObesityHelp: The Diary of a Fat Woman: Deny Deny Deny! Here's macmadame's great set of links: MacMadame's Profile And then you can google phrases like "vsg insurance" "vertical sleeve insurance" and then "appeal" and the like. You can also google terms for VSG + the name of your insurerer and/or state and see what you get. Best of luck! I'm pullin' for you. Britt

Thanks to the help of people on various boards I made many edits and finally decided to just get it done and sent. So it's off in the mail as of this afternoon and now I'll just wait and wonder until I hear back from them. If I had to place a bet it would be that they'll agree to remove the band but refuse to pay for a revision to VSG by moving the low BMI determination to their denial of the VSG. But at least I'll feel like I did everything I could. My husband asked me last night what I'd do if money didn't matter and my gut feeling was that I'd choose Aceves. He's so highly thought of and has such great experience. I'd rather not have to pay for the surgery (I'll have to use the money I was saving for a kitchen remodel). But in the end I know it's worth it. I was so thrilled with the lap band when it was working. I already know how life changing being able to manage your weight and eating is. I've updated the blogspot content to match what I finally submitted. That way if there's anything useful in what I put together it's available for others to cut and paste from. Britt

The TOS issue was resolved on a blogspot review. For new bloggers and new posts they do a scan to see if there are any words that trigger an alert for misuse by spammers and stuff. Everything was fine. Really sorry that it caused problems. I never blogged before.

Thanks Keith. I finally finished it off (and reposted the final version) today. It's now on it's way to the local BCBS. I actually expect that they will offer to remove the lap band but deny the revsion because I'm not >35BMI. Seriously, I think a lot of the insurance issues are related to weight discrimination. Pretty much any other diagnosis and and if the first treatment failed you'd have no problem getting a different treatment. Heck, if I had the symptoms I had without a lap band they would have been all over getting me in and covering whatever it takes to fix it. For the Fed BCBS stuff I posted on a few boards asking for others who were covered and got several public and private responses. I also did lots of googling on the variants of VSG and Fed Blue to find people who had been covered and the name of their doc. Then googled or looked up on Obesity Help a lot of the docs that were mentioned. Then called around to see what the various doctor and BCBS offices said. There were three states where the local BCBS administering for Fed Blue plan seems to have issues including Washington and California. In my state there are two BCBS offices that share administration of the plan and they disagree. The phone people are in the BCBS company that says it's covered but the pre-auth people are in the other company and say that it isn't. What's really frustrating is that there seems to be no Federal oversight of the plans that I could write or call to get this sorted out. I didn't include the doctor's names in the post because I didn't want to cause them any trouble in case they were using one of the old CPT codes for VSG (before it had an official code). And generally didn't want issues to come up in the states where VSG has no problem. If money wasn't a concern I'd probably already have gone to Dr. Aceves. But my hangup is what happens if I have a leak and need very costly emergency care. Who would pay for that. So if I can get some sort of coverage then I'll go with Dr. Cirangle in CA. There are a few local doctors here who do VSG but they just don't have the experience with revisions that Aceves, Cirangle and Hargroder have. I didn't really know as much about VSG and revisions when the pre-auth was submitted by the local doctor. It would be great if he could do it but they've only done about 100 VSGs and they want to do it in two surgeries six weeks apart. I just don't want that if it can all be done at once. And, heck, it's less than a used car if it comes down to self-pay for me. Well worth it. I loved my lap band while it worked. I think you should continue to fight on appeal. How good were your surgeon's notes? Will their office write a letter saying they had no choice? Much of the VSG info I used I got from Teresa who has a blog where she put her letter. I just added to it and wrote my own version. Also macmadame had posted a great list of studies and details that I referred to. Congratulations on your weight loss and improved health! It's amazing to feel like you're in control isn't it? I wish things could have stayed that way for me. I want to kick myself for not trying to get control before I regained so much weight. Britt

Hi all, Well thanks to the great help from the boards, I've got my appeal letter ready to ship off to BCBS. Anyone want to take a look? Offer me some advice? I've posted it here: http://vsgappeal.blogspot.com/2009/06/introduction.html ...and would love to get your in feedback. Thanks, Britt (forgive the multiple posts, not sure which areas get the most traffic)

Hi all, Well thanks to the great help from folks on the boards, I've got my appeal letter ready to ship off to BCBS. Anyone want to take a look? Offer me some advice? I've posted it here: http://vsgappeal.blogspot.com/2009/06/introduction.html ...and would love to get your in feedback. Thanks, Britt (forgive the multiple posts, not sure which areas get the most traffic)

Hi WASA, What's funny is that they didn't deny the VSG for the BMI reason, the denial letter states only that it's investigational. It's the removal of the lap band that they denied because of the BMI. Isn't that funny? Like no matter how much you're suffering you have to regain the weight AND vomit and not be able to eat to get the danged thing out. Or be lucky enought to have a slip before you lost much weight :-). Even if they brought out the BMI argument for the VSG I'd still fight them - I had a gastric restrictive procedure and it needs to be fixed so that I have gastric restriction again. My original surgery was covered and I met all the requirements so it seems like a continuation to me, not something new. If I went and asked for breast implants I'd be denied. But if I had breast cancer and a mastectomy and a year later asked for breast implants I'd be covered. They wouldn't deny me because I no longer had cancer. ahchancey, Would you be willing to share the doctor and/or state in which you had the revision? Part of my argument includes a list of all the doctors I've found with Fed BCBS patients who were approved for VSG. I've been calling the local plan admins in those states and confirming the coverage. So far, everyone says no problem. Of course my state admin said no problem too. They actually have two separate local BCBS companies doing the admin here and I think that's part of the problem. The group that does the customer service told me it was fine but the company that handles the pre-certs says it wasnt' and the other company was wrong. Sigh... Almost every day I think just screw it and I'll go see Aceves and pay for it myself. But now I've almost got the letter done, just need a blurb or two on why VSG is safe and mainstream and I'll send it off. Then I'm done and I'll either get it or book my trip to Mexicali. If I won the lotter I'd just book my trip and get goin' :-). Britt

Hi there! I'm working on my insurance appeal letter. I have a lap band that's failed (slip plus pouch dilation) and want to revise it to a VSG. I was denied on three counts. First, the removal of the lap band was denied because it wasn't deemed medically necessary. I figure maybe the insurance clerk who decided this ought to come and offer to hold my hair during the 4-8 hours per week I spend bent over the toilet sliming :-). They denied revision to VSG claiming that VSG was investigational. That makes no sense because I have Federal BCBS who have been covering VSG since 2008 and I just think that's an error on the local administrator's side. And they also denied it because I'm no longer > 35 BMI - well "no duh" my lap band helped me lose weight before it slipped. I can fight the lap band removal and "not morbidly obese enough" part pretty well and have written that part of the letter. But the part I'm struggling with is any additional documentation to fight the claim that VSG is investigational. So... Does anyone have verbiage from their appeal that they can share? Or a pointer to a published medical opinion or study that I can point to? Any help appreciated! Britt (Sorry for the other posts if you also frequent other boards - I'm trying to cast a wide net.)

Hi all, I'm just about to start my official fight with the insurance company (Fed BCBS) for denying coverage for revision to VSG after a lap band slip. I plan to have surgery with Dr. Aceves if I don't win on appeal and possibly if it looks like it's going to take too long (I've already gained back nearly half of the weight I lost). Here's my question... I've read a few stories of VSGers who had a serious leak that required considerable hosptial time and medical care. This really concerns me when I think about self-pay - I assume this kind of care could run in the tens of thousands of dollars if not more. But who pays for this in the case of self-pay? Does the insurance refuse coverage? Thanks! Britt

Why can't you have a fill sooner? I had a problem with my band and was unfilled and have regained some weight. I'd planned to revise to a different WLS but the insurance company is fighting me since I'm no longer a 35 BMI. I think what set me down the path is not being filled when I needed it. I'm getting refilled slowly, another one tomorrow, and hope that once I get back the restriction I had for the first 18 months I can get back to losing again. It's been very depressing. I've also started tracking what I'm eating online and that helps a lot. I've been trying out Daily Plate and Spark People. I've also found that attending Weight Watchers is helpful as is attending a lap band support group. Britt

I love both Wendy's chili and Taco Time's chicken chili. A small Wendy's chili with crackers, cheese, and onions is a very satisfying for me. And the calories go down without the crackers and cheese. Once in awhile I'll have a burger without the bun or with just half a bun. Mostly I try not to eat fast food because I have to fight myself to make good choices there. And because fries and buns and pizza have gotten stuck way too often to be appealing... Britt

I second the suggestion to try the powdered Peanut Butter. I've tried both Fitnutz and PB2 and like them a lot. Only about 50 calories for a serving. I like using it to flavor other foods, haven't actually tried making spread out of it since I don't really want to eat it on carbs. I was thrilled to find it. Britt

Oh wait, I see you have been doing liquids for weeks and you've had a GI. I agree, you should talk to your doctor. I ended up having an endosopy to take a closer look at what was going on inside. Is that an option for you? I think it would be good to get some medical help to figure out what to do... Britt

It took a total unfill and two weeks of liquids for my swelling to go down. You might just need to give yourself more time to heal... Britt