should I even bother?

Hi all...I'm a very bad member of this forum since I tend to post, get lost in other things or just become frustrated, leave, and then return again. But I would appreciate your help!

I have been trying to get bariactric surgery for many years. When I was still teaching, I could not because my insurance had a clause specifying no weight loss surgery for any reason. I did, however, try to fight this through a friend's lawyer, but to no avail.

Finally all of my health problems resulted in me loosing my hard-earned teaching position, and I was in for the fight of my life, literally. In 2007 I was hospitalized 6 times for different reasons and almost died 3 times. For the past year and a half, I have been working hard on recovery, but I am at a stand still because of my weight.

Starting last fall, 08, I began seeing a surgeon whose team was familar with medicare coverage of bariactric surgeries. Although he and his staff came highly recommended (and overall I was very pleased), there was a serious glitch. Apparently medicare will not cover surgery for people with bipolarism. I indicated that I had been diagnosed as bipolar and was currently on medication for this (although this diagnosis has been refuted several times) because I felt this was an honest disclosure. When I finally had my psych eval (after the 6 months of required nutritional counseling and just about everything else), I did admit to being bipolar. Now, due to this, I have been denied surgery. I became so depressed that I just shut down for a few months and didn't try to do anything about it. But I am plagued with comorbidities, including diabetes, mobility issues, sleep apnea, and chronic pain from fibromyalgia and arthritis, dispite the fact that I'm working hard to take care of myself and even exercise a little.

My question to all of you out there who have successfully been through the wringer is "do I have a chance at making this happen? If so, what should I do?" I am not under the care of a therapist, and I am having trouble getting in to see the surgeon for a consultation on the matter.

Thanks for any advice...I know that if I give up I'm giving up any chance of having a life rather than merely existing!

pfenix

Sorry I can't help, no experience but wanted to wish you the best and IMO you don't stop fighting until you have exhausted any and all possible avenues. 

Have you considered checking with the Texas Rehabilitation Commission?  We use to have a member that helped with this, I cannot for the life of me remember her name but I'd definitely check with TRC about any possible help, especially since you've lost your job due to health issues related to obesity.

Thanks for the support! Actually I went to TRC right after I lost my job and before getting on Medicare...I ended up storming out because after my paperwork came back from Austin, I was told that they would not do the surgery because I was not obese (at the time I was 300lbs at 5'). I asked the counselor to look at me and tell me if she agreed with them...the idiot did. Not too long after this I was too ill to pursue anything. So, that was part of my frustrating journey!

pfenix

  Wow ..  I had not heard about the "bipolar" Medicare exclusion.        I just assumed when Meidare approves a prodcedure, such as WLS, it is approved for all recipients ..  We have enough of those "games" with private insurance ..  

  Are you sure about that?   Maybe have the lawyer you hired earlier take a look into that for you and see if there might be a loophole or some way around it ..   (?)   

  I really don't see a logical reason as to why bipolar would disqualify someone form life-saving WLS ..  esp. if the patient is compliant, on meds and responding well to them ..   

   Dana has a very good idea with going the TRC route ..  The only problems you might run into is that they are already out of funds for 2009, and, if so, you may have to reapply right after the first of 2010 (they tend to run out fast after the first of the year, so I have heard).  Also, I had heard that no surgeons in the DFW area are presently accepting TRC funds for WLS, b/c of their history of "slow pay", so you may have to find a surgeon in another part of the state that will take it ..  

   Good luck to you ..   

I know!! The games, the games...believe me they don't decrease with Medicare. They have booby traps set up everywhere to try to keep from paying on neceesary treatments.

I guess if you read my post to Dana you will see that I've already tried and failed with that option. I believe my only chance of doing this is, unless my current surgeon is willing to take a second psych opinion, I will have to start the process over and not ever admit to being bipolar. I went off of my meds a few months ago, which may not sound too smart, but since I am not working and my life if pretty low stress, I am managing ok. Who knows?? Maybe I was mis-diagnosed all of those years ago? Anyway, I certainly feel the rollercoaster much more now; however, I do not feel as if I am in any danger. Hopefully, I can take action soon and make this happen! That I am in the position says way too much about the government; I hope it gets some WLS too!!!

Thanks so much for the response!

pfenix

I agree with the other poster, if you are bipolar and not being compliant it will only hurt in your quest for WLS.  I'd definitely see about getting proper treatment and/or psyc treatment as needed/necessary. 

So far the only thing that has hurt me in my quest for WLS is being compliant...isn't that ridiculous? But unless I get a diagnosis of being bipolar (rather than admitting to a diagnosis from '88), I'm not sure that I haven't been taking meds that cause weight gain for no good reason. So, clearly, I need to do as you and others suggest and find an independent psychiatrist to evaluate me.

Thanks for the help!

pfenix

I'm not a regular on this board, but saw the post on the main forum about this. I too have not heard the bipolar issue with medicare before this. Here's my view on it...

Are you positive this is why you were denied? Why didn't you have your personal psych doc do your eval or at least submit a letter with their approval/opinion of you getting the surgery? maybe this is something you can do the next time if you try again.

another thing...I think if you are bipolar not being in treatment will probably hurt your chances later because it shows you don't follow through with treatments in general.

personally to me it sounds more like the surgeon's office giving you the run around. unless I heard it from medicare directly, which you might have...I don't know, I wouldn't believe it. I'd want it in writing or something and then if you're up for it dispute it.

are you trying to go back to the same surgeon? maybe this is why you are having issues with getting in.

Well, I have not been under the care of a psychiatrist for many years; my general practitioner was prescribing my psych meds. I have been evaluated by several psychiatrists in recent years while trying to get help from TCR and while hospitalized for physical illness. They are not a very competent bunch from my years of experience. The one at Mainland hospital even thought I was drunk (while in the hospital for days!) because I could not verbally communicate due to a severe reaction to Neurontin (although I had to figure this out in my chemically screwed up brain all by myself!). So, I had no one that I was seeing to ask for assistance...I saw one of the psychiatrists recommended by my surgeon's office instead.

As far as my being declined by Medicare is concerned, i probably was not clear on this. The surgeon could not go forward with the surgery because of my bipolar diagnosis...his office manager called to tell me that I could NOT have the surgery because the practice would be fined for treating me if it went ahead with the surgery. It never even made it to Medicare.

I have a long history of medical conditions of many kinds and have always been a good girl and did as I was told. The end result...I nearly died more than once. Now I will always comply when I understand what I am to do and why...I did comply with everything that the surgeon's office asked of me, including the 6 months of nutritional counseling, loosing 20 lbs, etc, so, as far as I can see, the issue is not one of compliance but one of knowing the many loopholes that Medicare sets up and how to avoid or get around them. This is the kind of advice I would LOVE for someone to offer me!!! And, hopefully, my posting will alert anyone in my situations of this particular trap so that they do not step into it in the first place.

pfenix

I wouldn't give up.  It sounds like the they were saying you failed the psych evaluation so the doctor wouldn't do the surgery.  I don't even have the issues that you have had in your life and the psych my surgeon used made me come back for a second evaluation before she would ok me for surgery.  And believe me she needed a shrink more than I did.LOL 

Find another surgeon.  Go through the process again.  It will  be worth it in the end.  I can tell you from experience that this surgery can cause you to be depressed which is something I really was never told but it made since why they do the psych evaluation.  My family still tells me they think I need "happy" pills because I seem to stress out more now than I did before surgery. 

I wish you the best of luck.  PLEASE DON'T GIVE UP!!!!