Unapproved for Sleeve - Ready to CRY

[Tiffykins 672]

Ohhhhhhhhhh JoAnne that is good news. Sending you good vibes for even better news next week.

[mountain_lover 3]

I still may have a shot for approval!

OK, after I regrouped yesterday, I spent several hours digesting the content of my denial.

To my surprise I found two major flaws in their decision. 1) As I had referenced in my appeal, our medical policy on Sleeve Gastrectomy was extracted from a 2007 position paper from the ASMBS. The ASMBS "Executive Council has removed that outdated statement and has charged the Clinical Issues Commitee to review current data and revise the position statement".

http://www.asmbs.org/Newsite07/resources/sleeve_statement.pdf

I questioned, "How a denial could be made based on our Medical Policy where the source of the information can no longer be referenced?"

2) In my appeal, I also referenced "A systematic review of the literature covering Sleeve Gastrectomy through January 2009 which was published in June this year." This literature contained 36 studies with over 2500 patients. I knew for a fact that this study was never reviewed as part of my appeal, since I had to pay for a copy of this paper. (if anyone would like a copy of this literature for your own investigation, please PM me with your email address).

I emailed Central Appeals with my above concerns (along with the soft copy of these documents), and requested a re-review based on the above.

I received notification late this afternoon that the Medical Director has agreed to review the 2009 literature I provided, and will render his decision by next Tuesday.

I feel my odds of approval are 50 - 50, since the Medical Director could have refused to reconsider my appeal after the denial was rendered.

Please keep your good thoughts and prayers coming!

Hugs,

JoAnne

Hello jsm,

I hope and pray that everything works out ok for you. I know that this has to be so frustrating for you, but one of these days soon it will all be over and you will be on your way to a new life. Please let us know if you have the surgery on Nov. 10.

I have not been denied, but they did have to have some more information which I was able to obtain. Ellen, the lady at Dr. Husted's office, who takes care of the insurance, faxed it right away and we are waiting for an answer from them in a day or two. I am hoping that everything I turned in will be what they needed. They had to have a statement from me stating that I had been explained all the risks and complications of having the surgery. Also they needed a prescription form filled out by my family physician stating what diet I had been on for the months that I was doing my monthly weigh-ins since Feb. The stress and frustration have been at an all time high, but I have been trying to stay positive and just hang in there, hoping that everything works out for the good. In a few days I will post what I heard back from Medicaid. They will give me a surgery date as soon as I get approved.

Dr. Husted is booked up into the middle of Dec. but if other doctors have any cancellation of surgery, then they can pass the opening to Dr. Husted. Then My surgery date would be moved up to the new opening. If I get approved, then I could possibly be having surgery this month if that were to happen or at the least I could be having it in Dec. The longer it takes to get approved, the farther out my surgery date will be, because Dr. Husted only does the surgery on Friday here in Somerset and he only can do so many in one day. His dates get filled up real fast.

I know that you will be so happy to have your surgery over with and be on your way to losing weight! I pray that it will be soon and all this frustration will be over for you soon!! God bless you!!

[jsm 1]

Well it appears that I will still be denied for the sleeve. The Medical Director has stated that Sleeve Gastrectomy is not standard procedure. They are asking for my surgeon to provide in writing why He is choosing this procedure for me. Well, the problem here is that my surgeon is a RNY guy. He does perform the sleeve on patients that request it, but RNY is his surgery of choice. The sleeve is my surgery of choice.

What I'm pissed off the most is that all the 2009 studies that have been published, and submitted with my appeal, do not seem to be taken into consideration.

Next steps.....This has been an agonizing process. Last week I decided that I would re-schedule my surgery date for 11/17 (was suppose to be today). I put the appeal decision in the hands of God and would have whatever procedure (sleeve or bypass) based on the outcome of the appeal.

So, it looks like bypass it is. Yeah, I know I'm selling myself out, but I really don't have the energy to deal with this anymore.

I have an excellent surgeon and know that I will be in good hands. I have spoken to several of his patients who had the bypass (1 - 4 years out), and they have nothing but good things to say about the procedure.

The saddest thing is "leaving" all my friends on this forum. I still will be checking on you and wish you all the best! You are the Greatest!

Hugs,

JoAnne

[thinoneday 445]

you don't need to leave, come and share your experiences with us. . .i'm sure you'll want to talk at times and we'll be here when you need us. . .

[Chancie 65]

JoAnn-

Just because your surgery will be a rny- is no reason to leave here. We're all here for the common goal- to lose weight- to help each other thru difficult times and to support each other in good times.

encourage, support, be friends.... and that can happen here too.

I've belonged to groups where I'm th only sleeve person, but our goal are the same.

Their might be a few differences in our surgeries, but the end result will be the same!

Of course I understand you might want to be around others that had the same surgery as yourself- but we're all here for the united goal of weight loss, ideas, eating habits, and just all around support!

I've made the comment that if my insurance would have covered the RNY- thats where I would have been, but I sdtill connected with alot of people here, and I would have remainded a memeber here.

I just wanna say congrats to you! Get done what needs to be done! I know I'm behind you!As I'm sure the others are too!!

[carolyn24seven 11]

I am behind you 100% You will do fine. Please do not leave us. We care about you. I am so sorry you have this trial to go through. You will prevail. It will be interesting to see what different post op issues you will have as compaired to ours. Bet there are not as many as we thinkk. Keep posting, please.

[jsm 1]

Thank you so much my dear friends! Having your support makes this process so much easier for me.

I started my pre-op diet yesterday (a week late, but I was too stressed before to stick with it). Two days down on Atkins Advantage, Water and crystal light. It's not that bad when your head is in the right place. This time next week I will be on my way to a new me!

Hugs to all,

JoAnne

[mountain_lover 3]

Thank you so much my dear friends! Having your support makes this process so much easier for me.

I started my pre-op diet yesterday (a week late, but I was too stressed before to stick with it). Two days down on Atkins Advantage, Water and crystal light. It's not that bad when your head is in the right place. This time next week I will be on my way to a new me!

Hugs to all,

JoAnne

Hello jsm,

I hope all goes well for you. Everyone is so right, please don't stay away. Please let us know how you are doing, no matter what procedure you are going to have. We have got to know you on here and we all care. I am sorry that your Doctor does not see things the same way that you do and I wish your insurance company had different policies. One of these days maybe it will be so different and people won't have to go through what you and others, including myself have gone through trying to get approved for the sleeve. Everyone that gets approved for the duodenal switch, is having the sleeve and more done on top of the sleeve. When they realize that sometimes the more is not necessary and more risky, maybe things will change much quicker for everyone. The people that have very high BMI's and co-morbidities, maybe they do need the sleeve first, then a second surgery when they are healthier to have it after losing some weight: but for the people with lower BMI's and do not have lots of health issues, the sleeve seems to be the answer for them. It just seems so simple, If the sleeve works for so many, why do more than needs to be done? And why put the person at a greater risk of having complications? Also it would be so much less expensive for the sleeve procedure than the other more evasive surgery procedures.

I do have some good news to share with you and others. I have now been approved for the sleeve and I have a surgery date Dec.2. When I first started almost a year ago, the sleeve was not approved by Medicaid here in Kentucky. Dr. Husted assured me several months ago that in the near future it would possibly be an approved procedure. Well as you can see, now it is being approved for some. I am glad that I kept hanging in there. It has been a long wait, and I had many setbacks along the way, but I am glad that it did take longer so that now I can have the sleeve instead of the other procedures.

[Malaika 50]

JoAnn - don't leave us! There are others on the forum that didn't have the sleeve - Jachut has the band and so does JaffaSteve - you don't have to leave us just because you're having a different surgery -- Like Carolyn said - I am sure there won't be a lot of differences in the post-op issues and we'll be here to help you anyway we can!

[Tiffykins 672]

I agree with everyone that just because you're having RNY instead of the sleeve that you have to leave us.

We're here for you every step of the way.

[jsm 1]

Thanks Mountain_Lover, Tiffy and Vegas! I appreciate your kind words and encouragement. The support everyone has provided helped me through this past month.

Congrats Mountain_Lover on your approved surgery date. I am truely happy for you! :thumbup:

Although my surgery will be different, I'm still excited to be able to share my journey with everyone.

Hugs to All,

JoAnne

[Malaika 50]

Thanks Mountain_Lover, Tiffy and Vegas! I appreciate your kind words and encouragement. The support everyone has provided helped me through this past month.

Congrats Mountain_Lover on your approved surgery date. I am truely happy for you! :thumbup:

Although my surgery will be different, I'm still excited to be able to share my journey with everyone.

Hugs to All,

JoAnne

And we are looking forward to hearing all about it and being here to support you every step of the way!