Long Post, but Good News: Surgery Approved AND I HAVE A DATE!
I know that this will vary from person to person, but I wanted to share how my surgery journey has gone so far, for others that might have questions. I found myself searching for this kind of info while I was waiting for approval, going through the motions, etc. Of course, YMMV, but maybe this could help others know what to expect or what is possible.
Me: 30 year old female, with Type-II diabetes for the past 18 years. Always been overweight, even as a child, but really began to pack on the pounds when I started to need insulin to control my blood sugars.
I have massive insulin needs, and use a pump with U-500 (a type of insulin that's 5x as strong as Regular insulin). I take the equivalent of 300-400 units of insulin a day via pump.
Also have high blood pressure, high cholesterol and triglycerides and diabetic retinopathy. The retinopathy in particular has required 10 laser treatments and 6 eye injection treatments over the past year. That's a lot to deal with at 30. We don't have kids, and think we might want them, but my health hasn't made that an option, at all. The harder I've tried to control my blood sugar, the heavier I've gotten, and the harder it is to control. The insulin has been a vicious cycle for me.
I looked at several surgery options, but the DS was the one that made the most sense to me. Especially since my primary goal was to fight the diabetes and the diabetic complications. DS really seemed like the only real option. (My mother had a DS 9 years ago, and her diabetes was completely resolved for many years. Now she takes one pill, but she, too, had been on massive doses of insulin. I'm familiar with the DS recovery and life after DS through her, and knew it was something I could commit to).
I called BCBS of IL prior to meeting with the surgeon, to make sure that bariatric procedures were covered. I also requested a written copy of the guidelines. I learned that BCBS of IL covers the DS for patients with a BMI greater than 50. I also, personally, had met my out of pocket max for the year, so if I were to get the procedure done before year's end, I would not pay anything out of pocket. Sounded pretty good!
I had the first consultation with the surgeon in September of 2013. I met with a resident, the surgeon, a dietician, and a psychiatrist. My weight that day put my BMI at 49.4. The appointment was very straightforward--the literature said that the team would discuss the four types of bariatric surgeries offered and the pros and cons of each, but I came in wanting the DS, and my surgeon agreed that this was my best chance for resolution of the diabetes. Their materials said that the DS was for patients with a BMI greater than 50, but I was close enough, with serious comorbidities, so he wasn't concerned.
He described a relatively simple 2 week recovery, based on my "small" size for this surgery, my relatively young age, my diabetes being well controlled and the fact that I've never had any abdominal surgery before. He offered to sign off on up to 8 weeks off of work, but given that I have a desk job, didn't think more than 2 weeks would be necessary.
The surgeon asked for me to get a sleep study, updated blood sugar labs, an updated lipid profile, and a letter of support from my primary doctor prior to submitting to insurance. I already had an appointment scheduled with my primary doctor for the following week, so we drew labs then. I had already discussed my interest in bariatric surgery with her, so she was not surprised to hear that I had made this decision, and wrote a letter of support in just a couple of days.
Once everything was packaged to be submitted to the insurance company, it took 10 days for a decision. I began calling BCBS after 7 days to make sure everything had been received. I was very nice, but persistent, and followed up to learn the status of my preauthorization. The representatives were all very kind and understanding.
The day before my preauthorization was submitted by my surgeon's office, my husband was laid off from his employer. This meant that we would be moving to an expensive COBRA plan in order to continue coverage if he did not get another job right away. I don't know whether the medical review board at the insurance company is privy to this kind of info (that coverage is about to end) or whether that could have affected things. I would hope that it would not, but I can't say for sure, I suppose.
My first insurance response was a denial. The reason cited was that my BMI (49.4) was less than 50. They did not consider any of my comorbidities in making this decision, they simply do not cover DS. They would cover a LapBand or RNY, but I did not want those procedures.
My doctor's office first said they would help with an appeal and peer-to-peer, but then backed off of that and said that in their experience, BCBS would not budge. "Luckily" (is this lucky? I'm not sure, lol) I had gained about 6 pounds in the month and a half that all of this had gone on. I returned to the doctor's office to validate my weight gain, and the intake coordinator at the surgeon's office resubmitted the file to BCBS with my updated weight (now putting my BMI at 50.2).
I started calling around Day 5, and on Day 7 after this was resubmitted, I learned that the new weight had been received and reviewed, but the claim was still denied. They were accepting the new weight as valid and were ready to approve the preauthorization, except that they needed documentation from the surgeon's office that attested to the following:
"Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components:
1. Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program; AND
2. Behavior modification or behavioral health interventions; AND
3. Counseling and instruction on exercise and increased physical activity; AND
4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health"
I contacted the surgeon's office immediately, and they said this was submitted with the initial file. BCBS said no. Either way, the surgeon's office resubmitted with this letter. I waited 3 days after it was submitted before calling, confirmed they received it on day 4, and confirmed that they had approved the surgery on Day 5. YAY! MUCH REJOICING!
Except--oh, wait, when the Surgeon's office received the approval by fax, it had the same code twice, instead of the two codes needed for the DS. Intake coordinator follows up with BCBS. BCBS expedites the decision, and, finally, officially APPROVES the surgery.
That was Friday, today is Monday, and I HAVE A SURGERY DATE.
December 12, 2013.
THIS IS HAPPENING, and SOON!
*GULP*
I'm mostly excited, but a tad bit scared. I'd been so focused on getting this insurance hurdle worked out, and now, there are no more hurdles. I have my pre-op appointment on Wednesday, followed by an appointment with the anesthesiologist the following Thursday. And then surgery the week after that!
If I had to say one thing to everyone trying to get this through to surgery it would be don't give up, and be your own advocate. My surgeon's office was ready to give up, but I wasn't, and I didn't, and ultimately it was approved.
Sorry for the long post, but I think I would have liked to see more of this kind of post while I was anxiously awaiting a decision, and thought it might be helpful to someone down the line. :)
-Teri
Wow! Congrats on winning that fight. You have exactly the kind of attitude that is needed to really get the most our of your DS. I hope you have an uneventful surgery and a quick recovery. Be Happy!!!!!!!!
Insurance companies can be sooooo stupid.
HW 552 CW 198 SW 464 4/15/13 - Lap DS by Dr. Philip Schauer - Cleveland Clinic.
Thank God they approved. I had my original WLS RNY in 2000 because of diabetes and complications. I got really sick primary wouldn't recheck for diabetes. I went to urgent care and they said I had pneumonia it would take 2 weeks to feel better. So I laid in bed a drank slurpees for 2.5 weeks. My tongue and entire face had burned due to the high ketones. My mom said that's it your going to the er. I was so thirsty the wouldn't give me anything to drink I couldn't walk. So I asked moms to take me to the bathroom so I could use it. I was desperate I was going to drink out the hosptial bathroom sink. Well my mom wouldn't leave me alone in the bathroom damnit so I was like ok let me go to the bathroom since I lied and said I had to go. When I tried to go pain shot all through my body my kidneys has shut down. I was in kedoacidosis. My blood sugar was 1200. I was in icu for 10 days. No matter how I ate the right food and walked I couldn't get my sugar under 400. Frustrated and embarassed and tired of 8 insulin shots a day I had the RNYVwhich resolved my diabetes the day of surgery. So After 14 years after RNY Diabetes reared its ugly head again at a HGA1C of 6.2. I was so scared of being insulin dependant again. I heard the DS resolves the best so I had a revision. I can't even to imagine the emotional pain and suffering you are going through. Diabetes is a horrible disease. My grandmother lost her sight and both legs and eventually her life, my mom has had 4 brothers die from renal failure from diabetes in the last 2 yesrs. My mother died in September but was in renal failure from it, her identical twin lost a kidney at 25, a brother has lossed his eye.
I thank God you with your very severe case are able to get a tool to help you manage your case especially since you want babies and have none yet. I already had my 2 babies when I decided I needed it. Even if I doesn't resolve it to make it better will even be a blessing. But it may resolve it as it did your mothers I don't know if it resolves those who had it as a juvenile but heck we know if you do nothing it for sure wont resolve it.
Im so happy for you.
