OK - help - hope I am not getting too excited here!!

[SuzKelly 0]

I went for my evaluation today. Dr. was very nice. I felt at ease with him. Asked me if I had any serious health issues, which I do not (thank god) but I do have lower back problems from time to time (on prednisone right now for back trouble)...and I have bad knees from having flat feet and they do hurt me a lot.

When we were done he asked if I had any questions. I did ask if he thought there would be a problem with me not having a 5 yr history of obesity problems with my doctor (I've been seeing him for more than 5 years but no paper trail of my obesity). He says..get this:.."I don't think you'll have any problems with your BMI of 40 and your knee and back problems!!!!!! I was like REALLY?? now he's been doing this for 22 years so I guess he knows what he's talking about, but that's a far cry from what I have been made to understand......and he know the surgeons WELL that I have my consult with, so....

Anyone have an experience similar to this???

[Tiffykins 672]

My BMI was 45, and I had zero co-morbidities other than bad joints when I was initially approved for the band. I later revised to the sleeve after complications with the band. I would of been approved for the sleeve initially if I hadn't of gone with the band first.

[Bob_350lbs 105]

Yes, my PCP and insurance company. Their policy is that unless you have co-morbidities, a lower BMI of 39 (mine) didn't qualify me. That is ridiculous. The 1# cause of death in America is heart disease, directly caused by obesity. So, really obesity is the leading cause of death in America. Just because I haven't had a heart attack or stroke yet, doesn't mean morbid obesity isn't going to kill me. That is why I had to be a self-pay. Dr. C will do the surgery w/o comorbidities, if you are at least 70 lbs overweight. Oh, and guess what? My surgeon's post-op report revealed that I have a fatty liver, that can cause serious problems, and even progress to non-alcoholic cirrhosis of the liver, if weight is not lost. And, I had a large sliding hiatal hernia that went undiagnosed until my VG. My father died due to kidney failure caused by diabetes. He wasn't supermorbidly obese, just obese, and wasn't dx w/diabetes until after his triple bypass, at age 50. They ended up paying for 2 coronary artery bypass surgeries and a kidney transplant, but WLS? Out of the question. I knew if I didn't do this, I would have ended up just like my dad. I have that abdominal fat, which is the worst, and strongly indicates insulin resistance, which is a step away from diabetes. Diets rarely work, so this was close to my only hope to get my health back. I will be 52 in a couple weeks. I wish I would have done this sooner.

Edited September 17, 2009 by Steph_123

[SuzKelly 0]

Wow, Steph that sucks. I am sorry your insurance wouldn't cover it for you.

I guess maybe I need to clarify my excitement here. I think I got ahead of myself here. I have been excited all day thinking that the dr today was implying that I would get approved no questions asked, no documentation of 6 months weight loss program. So I went back over my paperwork that BCN sent me and it says :

The surgical procedures for severe obesity are considred established treatment options if all the following criteria are met:

The patient has a BMI>40 or a BMI of >35 with co-morbid conditions

The patient has been clinically evaluated by an MD. The physician has documented failure of non-surgical management indlucing a structured, professionally supervised weight loss program for a minimum of 6 consecutive months within the last 4 years prior to the recommendation for bariatric surgery. The 6 months program listed above is wavied for super morbidly obese individuals who ahve BMI =50. DOcumentation should include periodic weights, dietary therapy and physical exercise, as well as behavioral therapy, counseling, and pharmacotherapy as indicated.

Ok, now I am reading that to mean that even though I habe BMI 41 with the joint problems =- I still would need that 6 months documentation right?? Ugh. That just makes me sick really. I lost count of all my times joining WW (the same center no less, they know me like old family there)........and I did have a few times of 6 months consecutively and lost a good amount of weight..but no within last 4 years. Sigh. This is frustrating. :thumbup:

Edited September 17, 2009 by SuzKelly
added to post

[Oregondaisy 2,019]

Steph, thanks so much for making your font bigger. I really appreciate that.

My friend had open heart surgery which they said was directly related to her diabetes and her ins. turned her down twice. She finally gave up and went to Dr. Aceves right after I did. She was positive her ins. would approve her surgery after they just got done paying for her heart surgery. The surgeon here wrote the letter of appeal that said sleeve surgery would cure her diabetes. They turned her down again.

[kromrider 3]

The insurance companies are realizing that in the long run the WLS is cheaper for them. I guess that is a good thing.

[MacMadame 81]

Suzy - it really depends on your insurance and lots of doctors have no idea what the requirements are so you can't trust their judgment.

[Bob_350lbs 105]

I read that LapSF had a patient die WAITING for approval, after she appealed her initial denial. The day after she died, her family got a letter in the mail, approving her WLS. That is tragic.

Edited September 17, 2009 by Steph_123

[MacMadame 81]

Yes, Dr. C mentioned that once too.

I think this is part of why they don't *require* weight loss prior to surgery. They recommend it and it really is better for you if you can lose, say, 10 lb. They also have patients that they *strongly* recommend lose as much as 25 lb. But, if the patient tries and doesn't lose all they recommend, they do the surgery anyway. They said that their experience has shown them that, after a certain amount of time has passed, if the weight isn't lost, it's not going to be lost and insisting the patient lose it is just saying "we'll never give you surgery."

I've read lots of news stories about people who are SMO trying to get surgery and being told to lose 70 to 100 lb. and dying before they can do so. It makes me mad!

[TennJenn 9]

From the excerpt you posted about your insurance policy, I would think you are still going to be expected to do the 6 months supervised diet before you will be able to have the surgery. This is actually quite common. It does look promising with your BMI being >40...as long as your policy doesn't exclude VSG due to it being "investigational" which many insurance companies do.

I wasn't "qualified" for my insurance to cover me...BMI 34, hypertension & sever edema. If I had a BMI >40 I would qualify without any co-morbids, but I would still have to do a 6 month supervised diet & psch exam.

I'm not trying to rain on your parade, but I know how devastating it can be when you are so excited about something only to have it ripped right out from under you. Just prepare yourself for a fight...If it's easy, that's great, otherwise you'll be mentally prepared.

[MacMadame 81]

Also, make sure it won't be a problem if you lose weight during the 6 months and drop below a 40 BMI. Usually it isn't, but a few insurance companies will then tell you that you aren't qualified any more!

[SuzKelly 0]

Yup - you both are right. In all actuality - I feel rather silly complaining about the 6 month thing, since blue care network does NOT Owe me a weight loss surgery. So if I have to hoop jump - I hoop jump.

I just feel lost right now as to what I could be doing to help move things along. Once I visit with the surgeon hopefully I'll have a better idea of what to do, what to expect to happen, etc....with the process. Like at the seminar we got a packet of info. In it is a sample letter to take to PCP for him to write for a patient to the insurance company. So I wonder - do I try to get my doctor to get that done right now? Do I wait til after my surgeon consult????? Questions questions questions.

[TennJenn 9]

If I were you, I'd go ahead & see my PCP & get that letter. You will then be able to take that to your consult. I know one surgeon I researched required a letter of support from your PCP even for self pay patients...it was to be brought with you to your initial consult.

Good luck! I hope it's a speedy process for you.

[SuzKelly 0]

Yeah, that is good advice. I'll have to see if I can go by my doctor's office tomorrow and talk to someone about it.

Thanks

[Timetofly 0]

did you check with blue cross? I know when I went for my inital visit they told me I would need to do the 6 month supervised diet but when I called blue cross they told me in April 2009 they dropped that requirement, and the surgeons office has since confirmed that for me.