Health Net HMO questions.....

Hiya everyone.....
A while back I went to Health Net HMO's web site and looked up bareatric surgery to see if the  laparoscopic sleeve gastrectomy (LSG) was covered, and was happy to see that if was....but I went back today to re-read it, (because I was told today at a semanar that NO insurance covers the sleeve) I saw it was the laparoscopic vertical banded gastroplasty (VBG) that was listed.  I think that's a different surgery.....

Anyway, I read all the way through the bariatric surgery policy and at the end it said:

"In summary, the studies in the medical literature that have been performed note that long-term results of laparoscopic sleeve gastrectomy are not available at this time. Larger series from experienced centers are needed to evaluate the safety and efficacy of this procedure as a definitive primary treatment for morbid obesity. In 2007, ‘The American Society for Metabolic and Bariatric Surgery’ recommended data (≥ 5 yrs) on laparoscopic sleeve gastrectomy to evaluate long-term outcomes.  The only exception for the indication of LSG would be medical necessity for laparoscopic sleeve gastrectomy (LSG) as a stand-alone procedure would be when there is a clinical cir****tance for which Roux-en-Y gastric bypass (RYGB) or duodenal switch (DS) is contraindicated."  And it listed some things....none of which I have...

So am I to guess that Health Net HMO will NOT cover the sleeve (LSG)??  Is this fightable?  We have the Calif Dept. of Managed Health Care here that oversees health insurance companies in Calif and they are PRO WLS so I have some hope there.....however, things at hubby's work is slow, slow, slow and they might shut the whole place down and there goes our insurance so I don't want to draw this out...I really need to get the show on the road before anything bad happnes with my husband's job.

Has anyone had Health Net HMO that covered the Sleeve???

Any advice will be GREATLY apreciated!  I am soooo stress out of this I can't belive it..... You'd think the $900 a month we pay the darn insurance it would cover the best surgery choice for ME.

I finally heard back from Health Net today and they said that since my PCP has not denied my referral, they can't do anything about.  But he's just a making me go through the steps to get the referral.  She said I need to go back and see my PCP and try and get him to waive the rest of the stupid 6 month diet.  Well, why the hell didn't they tell me that a month ago??????? arg.....so I immediately called and made an appointment with my PCP.  I have already sent him the report from CDMHC that states that a forced, long term, pre-op diet is totally ineffectual and could be dangerous.  I'm going to take a copy of that report and complain about my edema (ankle/feet swelling) pain in my knee and ankle, sometimes my fingers go numb and I have a pain up under the left side of my ribs....all things that I'd never complain about, but darn it, I want my surgery!  If he sees that the diet is stupid and not doing good and my health is suffering maybe he'll waive the rest of the joke of a "diet"..............I HOPE AND PRAY...........

I'm just curious why you want the VGS and not a DS? Especially since it is covered by your insurance.

I originally wanted the DS however; Health Net says that I have to have a BMI of 50 or more to be eligible for it.  Also, in all the research I did on it, the high level maintenance after scared me (the high amount of vitamins, supplements and possibly iron infusions...iron makes me ill...found that out when I became anemic with my first child and had to take iron pills...yuk) and things are bad at hubby's work so I'm afraid he's going to get laid off and lose his insurance....which will make it impossible then for me to up keep all the blood tests and supplements that I'll need after the DS. 

Someone suggested that I try and get approved for the DS and have the VGS as the first procedure and just not go back and get the bypass part....but then again, I'd have a fight on my hands with trying to get Health Net to approve the DS since I'm at about 41 BMI right now.  I’m wondering if it’s just not worth the fight and If I should just be a good little Health Net customer and get the RnY because they say so.  I hate fighting; I don’t have the personality for it.  I get too frustrated and stressed out.

It's enough to make me scream..................

I understand your fears and frustrations, but ... you don't have to fight alone. You think you are tired now, imagine what you will be in 20 years if you don't get what you need now.

Take a deep breath, and remember this site is an invaluable tool. Go to the DS board, go to the VSG board, ask for advice. One way or another, you will need to arm yourself with information, and we have it. Perhaps someone who has been through this or something similar can be a great help.

Thank you Larissa.  I just love this sight.  Everyone here is so wonderful and there's SO much info.  I don't know how people researched their surgeries before this sight came into existence?

I have to take medication everyday because I have Bi-Polar, which has been well controlled for about a year and a half or so, but I do take a sleeping pill at night and I do take an anti depressant every single day, which I need.  I wonder how medication absorption is changed after a bypass??? 

I also wonder if that could be something that I could mention to the surgery to help get the Sleeve approved as a "medical necessity"???  However, I don't want to make too big a deal about me having Bi-Polar because I don't want to be denied because of that.  My psychiatrist (that I've been seeing for years) is very AGINST any WLS and I don't want to get him involved.  I'll go to a different psy for the check up that I'm sure I'll have to do pre-op.  You'd think that after three and a half months of this I'd be farther along in my pre-op journey....but I haven't even scratched the surface....and it's been 3 1/2 months.  This is moving along at a snail's pace.  Going to these stupid nutritional sessions twice a month is such a huge waste of time...6 months is half a year for crying out loud...that's 6 months of my life that I can't get back...for what?  Just to go through the steps my PCP says I need to do before he'll give me the all important referral?  Grrr……… I’m so sorry....just venting....

Thank you everyone for your encouragement and all your information. 

Wow Neely, thanks!  I've been dragging my feet in changing our PCP because I don't want to have to start a required diet all over again, with a new PCP.  I’m not sure if he’s against WLS, but it’s his medical group that has the forced 6 month “diet” before any referrals can be made.  In our area there’s 2 major medical groups and all the dr.s here belong to one of the other medical group.  3 ½ months ago when my PCP first told me that he’s medical group required a 6 month diet before he could even give me the referral to the WLS I immediately went home and called the other medical group to ask questions about their requirements for WLS and they, too require a 6 month diet before their dr.s will give a referral to a WL surgeon.   

I’m going back to see my PCP next week with that CDMHC peer review (which he hopefully already took a look at when I sent it to him a few weeks ago) and with a list of my health complaints, that, hopefully he’ll agree, will be taken care of by WLS.  I will ask him to waive the last 3 months of the stupid “diet” and will ask him for a referral right away.  I guess it will be then that I will know how he feels about WLS.  I’m not sure if he has to file an appeal to his medical group to get the rest of the diet waived, or if he can just go ahead and give me one next week.

Also, I only see my psychiatrist twice a year now since I’ve been stable for some time, so I don’t think he’ll be much of a road block.  I see a therapist weekly and, if they allow it, she’ll write the psy report.  Or I can go to a psychiatrist they referral me too.  I just won’t go to my psy… lol

I hope this trip to my PCP next week will help because I honestly do not know how to find a PCP that is approved by my insurance who ISN’T a part of these two medical groups in my area.  Any advice on that would be appreciated if anyone has an idea…. 

Thanks everyone for listening me vent.