Any state employees approved????

Well, I have one more month to go on my 6 month diet and then my paperwork can be submitted to the insurance for approval.  The downer of all of this is I am almost sure that I am going to be denied b/c the state employee benefit for surgery as strict criteria and I don't have any of the big three: diabetes, sleep apnea, or uncontrollable hypertension.  I do have hypertension but was never on medication and it has come down w/ the 13 pounds I've lost on the diet. So my question to all you wise ones out there...have any state employees been approved for the surgery within the last year or so if they didn't have one of those three co-morbidites.  If so, how did you get approved?  I don't think there are reassurances out there but I thought I would try .  Thanks!!! Rebecca

Not sure I qualify, but my check is certainly from the state every month! :) I'm a school teacher and going through the process, and have BCBS of AZ. I had them send me their qualifications and they were vague (easier to deny people if you aren't SPECIFIC)... But your message leaves me to wonder if I'll also be denied, with or without the six month diet (which they do not specify but which I've already started just in case).  In my case I've been diagnosed with hypertension by a (*&^'#@ of a doctor, and I didn't like the diagnosis (4 years ago) so I've been purposely skewing all of my blood pressure readings since then (is that awful?) I know some "biofeedback" techniques that can get my pressure down, and have used them every time I go to the doctor and my readings are fairly low (this was so I could get life insurance without paying three arms and two legs due to my obesity). The major co-morbidity that I am dealing with is GERD, which is destroying my larynx and which will see me out of a job in a year if nothing is done about it (I've been taking pills for it for a little more than a year). I probably also have sleep apnea, but it's never been formally diagnosed. So I wonder, if I don't have high blood pressure, diabetes or confirmed sleep apnea, will I get turned down too?  It's kind of funny, it's almost like the insurance companies want us to sabotage our weight so that we can prove we need the surgery. Isn't a BMI of 55+ enough? good luck on getting approved.

I hear ya on the evil insurance companies.  You are probably a little better off coming from your work because I think the teachers are in a separate insurance system from other state employees.  We don't use BCBS and so that is a major difference.  For state employees, the state is a self-insured employer which means they set the criteria and farm coverage out to different insurance companies, the insurance companies don't actually set the criteria, which makes it harder to win an appeal if necessary.  Hopefully it will be easier for you.  Make sure you harass BCBS for a copy of the criteria you need to meet for approval so that you can do everything right to speed your process.  Good luck!

Perhaps with the math teacher shortage, they don't want to lose teachers to co-morbidities (which they will lose me if I don't have this WLS).  When I called BCBS they apparantly have a "pre-certification" company to whom they farm stuff out: American Health Group (AHG).  So then when I called AHG they told me that there are really two sets of criteria, the BCBS criteria, and the much more restrictive AHG criteria. So if AHG certify me, usually, they said, BCBS will just paper pu**** along into the "approved" pile. They mailed me their (AHG's) criteria the next day.

The thing about this is that while some of the criteria is fairly simple: be 18, have recent blood workup, see the psychologist and take hte MMPI and be recommended for the surgery, and BMI > 40 for the last five years. Those are easy to comply with because they ARE straightforward... But these two sort of leave a lot to interpretation:

* Patient currently must have been under a physician's care and treatment during the previous 3 years for problems relating to the diagnosis and its complications, as evidenced by submitted notes and tests; and

*Patient must show documented history of "failed" weight-loss efforts or programs over the past three years as monitored by their physician Now, I've seen the doctors regularly over the last six years and can and will provide documentation of the same. I've been trying this or that diet forEVER, and I tell the doctors what I'm doing, what my success is, or my failure, and listen to their suggestions and try to change my dieting/exercising based on those visits. But all of those visits have been for routine things or specific issues not related to obesity (well a few of them were related to co-morbidities). So have I been being treated for obesity for the last three years? The second of the two mentioned above also is shadily worded... have I had failed weight loss efforts over the last three years? Yes!!!! Have I told the doctors? YES! Have they weighed me and made notes of those efforts and my increases or decreases in weight? YES. BUT have I gone MONTHLY to be weighed and tried to follow a specific structured doctor-ordered diet over the last three years? nosirree! So... Will they make me have a THREE-YEAR supervised weight loss program? egads, I hope not!  Ah well, we'll see how it goes.  In the mean time keep us posted as to how your own insurance thingie is going.

My husband is a state of arizona employee and I am under his insurance (Schaller Anderson) I was told without the big 3 co-mobidities that there is less than a 1% chance they will pay for it.  It is the state that set that critera not insurance company.  My approval is pending but vertually everyone said it will be impossible.   Did yours go through????  Tell me whats happened!  I havent been able to find anyone with my problem until I read this thread!

Well I have a different insurance than the other state employees (BCBS of AZ) and thus my chances of getting approved are probably enhanced. But at this point in time I have a few more steps to take:  1. See PCP Monday to get letter of recommendation for the surgery and to get my records sent to the bariatric center (who are doing the insurance paperwork).  2. See Psychologist Tuesday for consultation and to take the MMPI 3. See Bariatric Surgeon for initial consultation on the Wednesday after Labor Day to see if HE recommends the surgery and what type (I'm pretty sure it will be RNY though it might be DS if Insurance will approve it).  4. Wait for all the paperwork to arrive at bariatric center so they can send in the paperwork to the insurance company. 5. WAIT to see if I'm approved. My guess, I'll have to wait until mid to late september to find out if I am approved.  6. IF I'm approved, I'm off to LOSERSVILLE.... and if I'm NOT then It's off to appeals, or to do whatever new hoop they think is essential before they will consider approving the surgery.  On Planet Utopia the insurance company will look at my file and immediately stamp approved, and get back to the bariatric center 1 day after they get the application or whatever you call it. Then I would be able to have surgery on or around the one-week fall break, so I would have to take less time off work. Alas, I have a sad sinking suspicion that it might be Christmastime before I can have the surgery. And it's awful but my tummy said "ooh, I might still be able to make one more Thanksgiving Meal before cutting off my relationship with my good friend FOOD" (bad ME) If.... no.... WHEN I am approved, I will be sure to post a message to this forum. :)

My friend Maxine works for the state and was finally approved after a very long and hard battle.  Her profile is at http://www.obesityhelp.com/member/maxaz1/ I'm a state employee and my surgery was only approved after fighting for a year, hiring a lawyer and taking it to the state insurance commision.  That was over three years ago and as hard as it was then, I'm not sure how much tougher it could be now to get approved.  It cost me 800.00 to hire an attorney and I have to tell you that it was the best 800.00 I ever spent.  Gary Viscio (not my attorney) is supposed to be at the October OH event and he can probably give you some pointers for dealing with insurance.   Are you sure that you don't have sleep apnea?  Have you been tested?  I didn't think I had it since I wasn't really a snorer, but turns out that I was and that helped get me approved.   If you haven't been tested, get a pulmonary specialist to order a sleep study.  The other thing I did was see every kind of doctor you can imagine and got letters of medical necessity from all of them.  I saw a chiropractor, gastro-enterologist, orthopedic surgeon, cardio-pulmonologist, physical therapist as well as my pcp and surgeon.  I gathered every bit of evidence of every diet I had ever been on, listed every diet book I had ever read, got evidence of every gym membership and personal training session I could gather.  I don't know how much of what I presented made a difference, but I made sure that I got a copy of my benefits and had every base covered.  I even provided pictures that showed I had been seriously overwight for at least 5 years.  Even though I met all of the qualifications, my insurance company kept changing the criteria and denying for different reasons each time.  During the time I was trying to get appoval, they changed the diet criteria from 6 months within the last 2 years to 2 years of consecutive diets to 6 consecutive months of physician supervised diets in the last year.  Luckily, I'd been on a diet pretty much every day of my life for the last 20 years and could prove it. When we finally got to the last review, my attorney was able to find out who the reviewing doctors from each company were and selected Hayes to do do the final review because there was a weight loss surgeon on their panel.  If I have any advice at all, it's to not give up.  Hang in there and fight like hell.  Insurance companies know that most people switch insurance companies every two years on average.  It is not in their best financial interest to approve so they're going deny if they think they can get away with it.  Don't take no for an answer. Connie

It is very difficult to get approval from the State but Appeal. Appeal!  Another Biggie is the sleep apnea issue. Get a diagnosis! If it takes going and lying on your back the entire night (we snore more in this position) then do this! It is considered one of the more dangerous co-morbidities. Make sure you get this diagnosis BEFORE you submit to insurance. It is very hard to go back. If you do not test positive for sleep apnea then go for another test, preferably at a different clinic. Good luck, Mary

Thanks for the advice.  Unfortunately I already had a sleep study done and it came back that I did not have sleep apnea.  It said I had many unexplained awakenings but no apneas.  I live in a small town so there is no other sleep clinic to have another study done.  I really thought I had it when I was given the symptoms at Blackstone's seminar, the morning headaches, afternoon sleepiness, frequent trips to the bathroom at night, etc.  I wanted to have it so there was an answer for why I sleep like crap, plus it would make my approval easier.  But alas...that seems to be ruled out and my primary care physician has not ordered another sleep study.  I suppose I could ask Blackstone's office to order one and have it done in Phoenix but I don't know if they will do that or not.  So at this point the plan is to appeal, appeal as I am expecting a prompt denial once it is submitted at the end of September. Rebecca

It always makes me sad when see posts with people hoping they have sleep apnea.  Even if you do have sleep apnea, the cpap machine isn't always the answer to your problem, nor is losing the weight. Not everyone that has sleep apnea suffers from obstructive sleep apnea, some have central apneas which is when your brain simply tells your brain to stop breathing. It can cause heart attack, stroke, death. People do die from it. It really isn't something you want. Plus the cpap machine really isn't a big treat to wear at night. Outside of being incredible uncomfortable, you can even develope pressure sores on your face from the mask. There was a guy I know of about three months ago or so that was on the cpap machine, he went away for the weekend and didn't take his machine with him. He just figured it was a couple days. He had a heart attack and passed away in his sleep. I know it is frustrating to not feel well, and not sleep well, and not be able to get an answer from the doctor. And I do understand that you just want an answer to what is going on with your sleep. I know how frustrating it is to have something wrong and not have an answer to it. But it really is a blessing that you don't have something as serious as sleep apnea. You can ask your doctor about doing a at home apnea test. You just place it on your finger and attaches to a small machine. It is tiny. It might give you some ease of mind if you just want to double check. It basically monitors you oxygen levels all night long. If you have sleep apnea your oxygen levels will dramatically drop throughout the night. That is what is so serious about sleep apnea, and what causes the stroke and heart attack issues. You just place it on your finger and then bring the machine back into your doctor. He can then see if your oxygen dropped during the night. If it has, then he can send you in for another full sleep study.