Please Help I'm discouraged!

I've run into a big problem and am hoping you can help. After much research recently at my works our open enrollment time I chose to stay with my Regence BCBS PPO medical insurance. Because it said it will now offer Bariatric Surgery (before it was excluded) I have carefully followed all the criteria (see exerpt from coverage plan below) and been attending local support groups through an excellent program at Samaritan Baritric programl in Corvallis. I've done a sleep study, been to a nutritionist and a psychiatrist and my PCP is writing a letter of support with all the documentation required. I had a question early on about what "A Center of Excellence" was. Kim at Samaritan Bariatric checked with BCBS and they said a Center of Excellence was any one who was contracted with BCBS. With that point settled I moved forward in the process. However, someone from this list wrote me and said she inquired and BCBS said told her a very different story. They said the sole "Center of Excellence" in Oregon is in Portland OR at Legacy Good Samaritan. Please understand how disappointing this news is. Portland is 90 miles away and it would be very difficult to have this done so far from home. Especially when there is an absolutely excellent program right here in my home town that people absolutely rave about. I have done all the research and the pre work seen the surgeon and developed a relationship with support groups people and the staff at Samaritan Bariatric. I have a lot of confidence in them and feel comfortable here. What can we do to see that Samaritan Bariatric is designated a "Center of Excellence" (see excerpt from plan below) . They have done hundreds of this type of surgery and are highly recommended and are used by many insurance companies. Surely the insurance should be able to see how beneficial it would be to undergo this procedure at a place closer to home, so participants can attend follow ups and support sessions more easily which leads to a successful outcome? Since PEBB Regence BCBS of Oregon insurance has now included this procedure I am sure they will see a lot more people from this area with this same predicament. Surely it would be beneficial for them to designate more Center's of Excellence at least one more centrally located to most of Oregon like the one here in Corvallis. I checked into the Legacy Hosp. website and see they have classes one can attend for $400. but not sure whether insurance will pay. Also they are on a weeknight starting at 6:30, how am I supposed to be able to get there from Corvallis after work in time to make the meeting, its a 2 hour drive. I am so discouraged. See page 45 of the plan at the following link to the BCBSO plan http://oregon.gov/DAS/PEBB/2005OE/PDF/2006benbookI/rbcbsp46.pdf (the following is the excerpt from the plan on page 45) Surgical treatment of morbid obesity The plan will only cover the Roux-en-Y gastric bypass for the treatment of morbid obesity, and only when the criteria defined below are met. No other surgical procedures are covered by the plan, including, but not limited to gastric banding, adjustable gastric banding, vertical banded gastroplasty, mini-gastric bypass (gastric bypass using a Billroth II type of anastomosis), distal gastric bypass (long-limb gastric bypass), biliopancreatic bypass, and biliopancreatic bypass with duodenal switch. The Roux-en-Y gastric bypass may be covered for the treatment of morbid obesity when all of the following criteria are met: 1. BMI > 35mg/k2 with a diagnosis of diabetes; or BMI 40mg/k2 with any comorbid condition; or BMI > 50 mg/k2 with or without comorbid conditions. 2. A 6-month work-up is completed that includes all of the following: ? Dietary counseling and education; and ? Medical evaluation; and ? Psychological evaluation; and ? Weight loss of > 5% over the 6 months 3. Surgery is performed in a Center of Excellence recognized by Regence BCBSO for the performance of such a procedure.

Rose, you are experiencing the same discouragement so many other state employees are encountering because yes, there is only one place thus far to have the surgery. I hope that changes, BUT...... You need to stop and regroup. Do not get wrapped up in a battle to get the surgery done locally - especially before you have it. You'll likely be in for a long hard battle and you may end up finding they deny your surgery if they decide you are too difficult. I have seen this happen to someone in another state on my surgery date message board a couple years ago. I paid out of pocket to go to Mexico to have this surgery because the ONLY insurance we are offered down here is BCBS and they do not cover bariatric surgery. I have to tell you, you need to count your blessings and not dwell on the fact that you are not getting everything you desire, and concentrate on the fact that you are going to have this surgery covered by insurance. More and more insurance policies are excluding bariatric surgery where they once covered it, so I see this as no small miracle that it is covered by the state right now. If anything, I expected them to take away the benefit from Kaiser patients as well. 90 miles is not bad. If you live in most other parts of the state you will travel at LEAST 90 miles to have the surgery. Medford isn't exactly Podunk, but until the last year or two there were no bariatric surgeons in our area. That means you travelled 1.5 hours to Klamath Falls or 3 hours to Eugene. Yeah, it would be great to have a local surgeon, but look at the bigger picture. Concentrate on the fact that you will have an opportunity so precious few people will be afforded. Change your perspective and move on from here. You can always argue your point after you have surgery, but don't waste your time fighting this fight right now. You could lose out big time. Good luck to you - I hope it all works out wonderfully for you! Dina

I agree with Dina. Keep your eye on the prize. I promise you it will be worth it! You will look back a couple of years from now as I do and not believe you even did what you did to make it happen. I had a real low when I was with Kaiser and after two years in the bariatric program (attending support group and getting to know peers) I knew it was never going to happen and had to change insurance companies and start over. The logistics can be worked out. It may be better to go forward with the channel that has a green light, rather than try to change the minds of an insurance company. It seems like a no brainer to service your area in such a wonderful hospital that has a great bariatric program, but the insurance companies will stonewall any way they can. I still bang my head against the wall trying to make sense of how my insurance company pays prescriptions and in-network vs. out-of-network doctors. I would take the path of least resistance. You will get great care with Good Sam here in Portland. Good luck to you! Patty

OH' GIRL!! If you can have surgery only 90 miles away you are very blessed. I had to drive from Spokane, WA to Kirkland, WA to see my surgeon. That's over 5 hours and I was happy to do it because I really need the surgery. Luckily I have moved to the west side and now I have a surgeon who's only 30 min away, but I would have continued to make the drive if necessary. Really 90 minutes is nothing. I have found that jumping thru the hoops in this process takes a lot of sacrifice. Missed work and extra expenses just to name a couple. Ultimately it will be worth it. Best Wishes, Holly

Hi Rose! Dina, Patty, and Holly have given you some great advice! I live in Salem and had my surgery at the Legacy Good Sam. Hospital. I make the 45 minute drive each time I have a follow-up appointment. Adding years back to my life has been worth every penny in gas and every mile I put on my tires. Plus, my surgeon and his staff are truly wonderful people. Good Sam is having a FREE orientation in Portland on Jan 10th (from what I remember). You should call 503-227-5050 to enroll. Good luck! Charity

Hi Rose. It sounds like you have been given some very good advice. If I may add one more little tidbit, I had my second surgery at Legacy Good Samaritan in Portland, and the care givers there were just wonderful. It's a very good support system. Good luck, and do let us know what you decide because it is ultimately your decision to make. Peg

Hi Rose. I was just thinking about you today and wondering how you're doing. Take care. Peg

Hello all, I am new here. I have the same insurance as Rose. I have no idea where to start to find out about having the surgery. Can somebody point me in the right direction? Is there a specific phone number in Portland to get information? Thank you for any help you might be.