New and feeling Lost!!

4jin · 10-31-2007, 03:17 PM

Hi ya' all who read this thread.
I just want to be heard and find a connection with people who have a similar story.
Here it goes...
I have been overweight all my life. I can only remember a few times when I wasn't. I grew up with two brothers who ate what they wanted and were at normal weight. My mother would go out of her way so I would diet. I have been on every diet imaginable from SlimFast, to diet pills from GNC, joined gyms, Doctor paid for medically diets and exercised programs, soup diet, cabbage diet, south beach, WW,.....on and on.... Some worked others were a joke..... But needless to say gained it all back. I am right now the biggest I have been in my life. I am so unhappy with my weight. I feel as thought a different person in my is trying to get out but none of what I do helps for the longterm.
I am tired of feeling the shame, of looking in a room to see if I am the biggest person or not.
but mostly I am tired of the loose, gain...loose gain...gain twice as much as I lost...etc...
I researched last weekend gastric bypass as it has been something on my mind for years now..but couldn't help feel guilty or like a failure for turning to what some people refer to as the "EASY" way. I know I need a medical intervention to win this battle and be at a lifetime healthy weight. So I got over it and researched this past Weekend and came across this LAP-BAND^®. I love it...I have decided this is what I need.
I scheduled to what I thought was the informational seminar yesterday. It was an info seminar alright, but for Opti-Fast...what the crap...insurance does not pay, can only be cash or financed with the lender of the choice and cost $5,000. yeah right...walked right out... waisted 4 hours of my day in traffic, and away from family for that!
So I called the number I called initially and was finally scheduled for the correct seminar but i have to wait until 12/5/07.
My only concerns now are this.
I am 5'2" and W 233lbs home scale.
No comorbidities.... have documented doctor program from beg of this year in January until July 2007. Prior to that back in 2005 was the last doctor monitored program I did. I can probably get weight info from my gynecologist when my daughter was born back in 2002 of my weight prior and after pregnancy as I believe was a bmi slightly under insurance guidelines. I will have AETNA HMO effective 01/1/2008. I am snoring at night and began having asthma which I believe is weight related as well.

My questions are as follow:
Does anyone have any advise of how my case looks?
Do I stand a chance at getting approval without a long battle?
What is the process after attending the informational seminar all the way to the doctor's submittal to the insurance?

HELP desperate to know!!:help:

sghatl · 10-31-2007, 03:28 PM

4Jin, where do you live?

4jin · 10-31-2007, 03:38 PM

I live in Dacula, GA.
I will be attending the seminar and hope to pick my surgeon from Emory Hospital in Decatur, GA.
A bit of a drive but hopefully worth--it!

short1 · 10-31-2007, 03:54 PM

4jin,
Your BMI is high enough, but it just depends on your insurance co. Talk to your family Dr. and get a sleep study to find out if you have sleep apnea. Call the Dr. where you are having the consult and find out if you can do your psy. or attend any meetings that will look good for the insurance co. Call your insurance co. and find out what the requirements are and get them in writing. Don't depend only on the people at the Dr. office to talk to your insurance co. call them yourself. Are you depressed? My Dr. said I was depressed due to my weight. I also had my gynecologist and family Dr. write letters for me saying I would benefit from LAP-BAND^®. Give your Dr. a list of all failed diets. Brain storm! Good luck.
JP

sghatl · 10-31-2007, 04:03 PM

4Jin, I live in Lilburn. I went to the seminars at Emory and at DeKalb Medical Center. I will be having my surgery at DeKalb since Emory is not an accepted bariatric center for Medicare. Medicare requires the center to be a 'Center of Excellence' which Emory is in the process of procuring. Just haven't got it yet. Both Hospitals have seminars. I, too, called Emory and got set up for the Optifast first. I then attended the bariatric seminar. I found out my BMI was too high for surgery so I ended up joining the Optifast weight management program at Emory and have lost almost 50 pounds on it. I now qualify for surgery. Once you go to the seminar, you set up an appointment with the doctor and start your journey for approval. I was required to get clearance from my primary care doctor (some have to have a referral but my insurance doesn't require it), a pulmonary clearance, a psychiatric clearance, a cardiologist clearance (not every one has to do this one), and see a nutrionist. When I completed this the doctor's office sent in for insurance approval. As soon as I got approval, I saw the surgeon a second time and surgery was scheduled. I also had to have an upper GI for him and if I had had a gall bladder, I would have had to have a gall bladder scan. All of this is not required by the doctors but by some insurances. It's all going to be up to what your insurance requires. I was not required to show or prove a diet history but some insurances require it and some require a 3 to 6 month doctor's supervised diet program. Check out your insurance requirements.

sghatl · 10-31-2007, 04:05 PM

I think you can have surgery in Gainsville too. Check around.

4jin · 10-31-2007, 09:18 PM

thanks guys all this information is great!!!
My insurance currently are primary BCBS HMO and secondary BCBS PPO. But of course have to have a but.... eff 1/1/08 I will have AETNA HMO as primary and AETNA PPO as secondary.
Any info on these insurances anyone?

sghatl · 10-31-2007, 10:47 PM

Be sure and check out the Georgia thread under USA LAP-BAND^®^® Support. Several people there have used Dr. Lin or are going to use him.

LynseyBcat · 10-31-2007, 10:53 PM

<p>You may want to check other doctors. When I went to my seminar, they didn't talk about any "products" and they were also very helpful with insurace information. They said the cost would be $14,000 and I've checked everywhere and its the same going rate everywhere. I would check around some other doctors maybe.</p>

4jin · 11-01-2007, 10:51 AM

:faint:Emory is out of control...!!! I called yesterday and scheduled what I thought was the info seminar. She gave me a date of Nov 7 right....well guess again..
:rain:I got a call this morning that the session was closed and by error i was double booked. For sure when it rains it pours!!
Unless someone calls last minute for cancellation I have to be reassigned to the next meeting which is not until DECEMBER 5!!

What....R U PEOPLE CRAZY.....I can't take this madness.

So I did what you guys suggested I brainstormed....found out both BCBS and AETNA gladly work with Northside Hospital...
Even better news....So when I do transition from BCBS to AETNA I should not have any problems at all!!!!

Northside here I come...so I called them up...
YES! No round abouts of Optifast meetings or anyother one of those things!!!
was offered next Wed Nov 7!!!
yeah...yeah....:bounce:but it is at 7:30PM....
can't homework time...etc....

so I had to take the next one I said scared when is the next available...... crossing my fingers hoping ....please..please...please..
not December ....

YES!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The following one available is Thursday Nov 15th...:bounce:the nurse must have thought i was crazy!!! I was that happy!!!

now that's what I call service..!

She even explained I will be emailed instructions/information to help decide if surgery is the right journey for me...if it is which method would be best and what medical information I should start gathering.
Finally results!!!........ My journey is on it's way.....:biggrin1:
I should be able to schedule appt with surgeon on the spot after the meeting session....AWESOME!!:bounce:
Take that Emory....:clap2:

Thanks guys

short1 · 11-01-2007, 01:02 PM

4jin,
I have BCBS of Il. and they paid 80% after meeting $500 deductable. I had to have a psy. eval., letter from a Dr. saying the surgery was necessary, meet with a dietician, have a thyroid test, and last two years of medical records. Keep callin the insurance co. weekly after your paper work has been submitted. They said I was their mosy proactive patient ever, but it paid off. Good luck.
JP

sghatl · 11-01-2007, 02:13 PM

I received approval from BC/BS in lessthan a week.

**Kat817** · 11-01-2007, 03:02 PM

Yea!!! You got the needed info---and that was whether the new insurance will cover WLS at all. Some companies opt out, even if the insurance company offers it. Now that you know they do....you can get busy!!!

Call them and get a list of what they require, and then begin filling it in....make sure to copy EVERYTHING. Also take detailed notes, as to who you speak with, when, what they said--everything! When you know what you need you can begin calling in records from other Dr.'s offices. Making lists of previous diet attempts. Look into having your apnea diagnosed----most insurance will require a sleep study anyway, so it would just be a step in the right direction. You can even take very candid photos to show that you do need the surgery---it can all be included in your packet sent to insurance. If you have ever taken meds for high blood pressure, or had a high cholesterol reading, any of that is good info to include.

Then keep in mind that some insurance companies have an automatic denial---do not be afraid to appeal the decision, some of them, it is not even looked at until appeal!

Hang in there, look around this and other sites, ask any questions you come up with. WLS is not an easy way out. It is something you are doing to improve your health. You will work with the band if that is what you choose, but it makes losing the weight a do-able thing---it is so much easier making the right choices when you are not starving all the time, and there is the little silicone fist wrapped around your belly keeping your portions small. I love my band---and I encourage you to look into it as well as into the bypass. Whatever decision you make, make sure it is a well informed one.

If you have someone who will be with you following the surgery---see if they can attend the seminar with you, it makes everything easier, when there is more than one of you trying to take in all the info, and then afterwards they are informed as well!

Good Luck!!!
Kat

4jin · 11-01-2007, 07:39 PM

kat817
thanks so much for your refreshing info.
You are a true inspiration. 103 lbs lost WOW!!
I went online to obtain a copy of the certificate booklet and it says I have to call and ask for it....convenient right....
I will be calling tommorrow and requesting the requirements be faxed to me. I will began working on writing dr offices and tel#'s so I can began requesting records.
Hope to hear more advise from you soon.

4jin · 11-02-2007, 11:45 AM

Good Morning!!!
I listened to all of the help and advice I was given. I called my HR...I can keep my same insurance for next year..!!! Yes....
So I will still have BCBS GA. HR did not know if LAP-BAND^® is covered so she gave me the number to contact our benefits coordinator.
I called holding my breath...
I spoke to a member services specialist I think her title was...she was great. I just gave the group code and she pulled my employers policy. She verified it is covered. She gave me directions how to obtain a physical copy of all the medical policy, the guidelines, requirements, CPT codes, etc.. She even gave me info for future if medically necessary can have tummy tuck covered as well but must loose 100lbs. WOW!!
I printed the policy and it looks like I meet all the general guidelines, now I just need to start the process of requirements once I meet with the surgeon...the usual...mental health assessment, psychiatric profile, have doctor explain outcome...etc... etc....
Requirements:
Medically Necessary:
1. BMI of 40 or greater or BMI of 35 with co-morbid(just one)(sleep apnea, obesity cariomyopathy, diatetes, hypertension)
2. Patient must have actively participated in non-surgical methods-these are evaluated and appraised by the physician requesting authorization for surgery AND
3. Physician requesting surgery must confirm the following:
Psychiatric profile, post operative expectations explained and addressed, undergone a preoperative medical consultation, mental assessment, explained risks, benefits, uncertainties and procedures of surgery, pre and post diets and nutritional counseling (yes they cover it with a certified nutritionist/dietician), and counseling for exercise, psychological issues and support resources.

I am so excited I can barely contain myself....
I can breath the odds for once are in my favor.....
Needless....from reading other threads I am aware the small battle will begin....until obtaining official approval.
but can't help it.....can't hold back the excitement.