Question:
First Dr. Visit Today-VERY Discouraged
I will be 26 in less than a week, 5'6", 260lbs., and, after doing a lot of investigating and thinking, decided to see my physician to discuss options and the process of getting started after recently sharing my desire to get WLS to my family and friends and gaining tremendous support. I have never been so discouraged and confused. I should preface everything by saying when I had to have my gallbladder out 9 months ago (which, I believe was a result of all the weight), the surgeon privately spoke with my parents and said I was an ideal candidate for WLS. Since then I have been plagued with health problems and been in the hospital a total of 4 times since December due to what I, again, feel are issues related to my weight. In fact, the last time I was in the hospital was when it hit me I needed to get help because I saw 'morbidly obese' on the doctor's chart accidentally. My main concern was the impending battle I figured would ensue with my insurance provider, Personal Care, however, after meeting with my PCP today I think that's only a portion of what I'm up against. He told me that I would need to wait a minimum of 12 months, get a pedometer, start eating less , exercise more and then in about 6 months submit to Personal Care. This was all said after I had just gotten done telling him that I couldn't get up the two flights of stairs to his office without feeling like I was going to die. In addition, I barely eat that much as it is and do not drink or do anything that could add to my obesity. I am confused. I thought it would be, at most 3-6 months to get this ball rolling. I am more than willing to endure that, but twelve months? And then to run the risk that Personal Care rejects me in a year +?? I couldn't handle that. I'm young, I want to travel, engage in sports again and have children in the next few years and know I can't until I lose the weight but now I feel completely dejected. Should I return to the surgeon who took out my gallbladder and see if that would be a more aggressive way to go?? — ens1980 (posted on August 28, 2006)
August 28, 2006
Hello! Have you consulted with a bariatric surgeon yet? I would suggest
that you do that. I know that most of these doctors know how to deal with
insurance companies. Many do require a supervised diet program prior to
approval. Although it sounds as if your PCP knows what your insurance
company requires, visiting a bariatric surgeon would be a good first step
towards your journey. Good luck!
— Sheri A.
August 28, 2006
Hi Ellen - I would only recommend what I did after following the process of
all the testing and insurance denial, but after a long up hill battle I
ended up going to Mexico for my surgery. I had the best care and am now
down to 124 pounds. It is an option that you can keep in the back of your
mind in the event all else fails. It only costs $12,000. Please feel free
to contact me if you want any details...
Kim
— kimmy
August 28, 2006
I was in your situation of not wanting to wait 1+ years for the surgery,
and then not being sure if I'd be approved. I opted to self pay outside
the US. I am having surgery in Bogota, Columbia with Dr. Valencia on Sept.
14th. Since I am not working and have a bad past credit history, I was
only approved for a loan w/ a cosigner for half of what the surgery costs
altogether (total coast about $14,400 for an all inclusive package). My
parents, knowing my health and life depend on me losing weight financed the
loan for me. I do not know your financial situation, if it's as bad as
mine. It took a lot out of me to ask my parents for help. (I'm 31 yrs.) I
am a post graduate student. But, I was relieved and overjoyed when they
agreed to help. I am paying the loan monthly instead of them. Perhaps you
could self pay w/ the help of family financing it and you making payments.
It's something to look into. Check out the South of the Border forum on OH
for ideas for hospitals and surgens. I am glad I did and looking forward
to my "rebirth" day.
Jennifer
— Jennifer K.
August 28, 2006
Hi Ellen, don't be discouraged. Another suggestion (besides talking to a
surgeon) would be to call your health care provider and ask them WHAT they
require. Mine required only 3 months of weight loss management with my
Primary care physician. During those three months, I also continued with
all the testing required from the surgeon for surgery. My initial meetin
gwith the surgeon was March 15th- and my surgery was July 20th. So it took
about 4 months for me.
Good Luck!
— tparr
August 28, 2006
Don't let anyone discourage you!!!!! Find a PCP that supports WLS. You
also need to find a bariatric surgeon that specializes in WLS. They will
lead you down the right path on what tests are required by your insurance
company. I would say about 95% of insurance companies require some type of
supervised diet - ranging from 3-12 months. Mine was 6. Also call your
insurance company and, get in writing, their policy on WLS. Your (or your
spouses) employer - you need to make sure they don't have an exclusion for
WLS. I'm 25 so I understand how you don't want to wait...I want the same
things you do. Also, what are your co-morbities? You'll need all this
info for your surgeon. Good luck!
— platypus
August 28, 2006
Hi Ellen,
I just want to say "Do not give up" first of all. And I agree
with a previous post that you should call your insurance company and find
out from them what the criteria for the wls is. They will not hesitate to
give you this info. My insurance company requires 3 month diet w/in the
last 6 months. Others have different criteria, so you will need to call
them directly. Best of luck to you, and, as I was told up front... Be
patient. I am sooo trying myself to be patient, not had surgery yet, but
am still working on it.
— Jean N.
August 28, 2006
This is such a sad story. That being said, my pcp did the same thing to
me. She wanted me to wait longer to but I went in there determined and
with all my facts straight. I knew what I wanted and who I wanted to do it
and he was someone that she knew. She and I talked several times before I
actually got her around to my thinking. It is a sever and drastic surgery
and shouldn't be taken lightly. It took me about 10 months or so before
they were able to schedule a time for me to have the surgery. You have
alot of tests that have to be run and more when you have been ill. I know
because I too had been ill alot before the surgery. I also went for an
exercise evaluation. They gave me a pedometer and told me to walk. They
also told me to slow my eating down and to try and lose a few lbs before
the surgery. It is essential that you try and do some exercising and it is
a big part of post op care as well. This is no in and out surgery it is a
true lifestyle change. You really have to want to change your whole life
to have it done. God bless you that you have taken the first steps but
just keep up with your pcp and he will change his mind. It doesn't ever
hurt to have a second opinion about the surgery and I would certainly go
back to the surgeon and get his opinion too. Good luck and if you really
want it a year is not really that long that you can't wait for it.
— vickicarson
August 28, 2006
I would also say not to give up Ellen. I agree that the first thing I
would do is call the insurance company and clarify what their requirements
are. Some insurance companies themselves require a period of time you must
weight and demonstration that you are on a weight loss program, etc. Cigna
was like that when we were on it. Fortunately by the time I had mine we
had changed companies. Then find a good WLS doctor - many know how to work
with the insurance agencies. My doctor handled everything basically - I
didn't have to get involved with my insurance company. Good luck and don't
give up!
— dwhit54
August 28, 2006
Well I agree with everyone else, go straight to the Bariatric Surgeon. I
have never had a PCP (the ones I ever did have died of moved away), so I
never got the opinion of one. And I was only 22 years old when I had
surgery (but I was heavier than you at 369 pounds). Sounds to me like your
PCP is not "into" Bypass Surgery and is trying to make you lose
weight on your own (if you could do that wouldn't need surgery would ya?).
— GAYLE CARMACK-LYONS
August 28, 2006
Hi Ellen,
Some doctors also want to see if you are serious enough to change. Your
doctor may also have given you the 12 month period knowing it could take a
while to work everything up. Don't give up and don't be discouraged! It is
well worth the wait.
I agree with some of the others, call your insurance company and see what
they require, then go to your pcp armed. Also, research finding a surgeon
who specializes in WLS. Get your ducks in a row and show your pcp you are
serious about a new way of life...Best of Luck to you in your journey!
Monica
— MonicaCarr
August 29, 2006
Ellen, first check by calling or if possible going in person to find out
what is required by your insurance. Is this through work or another Social
Program such as Medicare? What is the Possibility of changing Insurance
companies? If you find a conflict as to what your insurance company tells
you and what your Primary has told you, IT'S TIME TO FIND A NEW Primary who
is WLS Friendly. Either way start going monthly to progress on a
"Doctor's Supervised Diet" making sure it's documented in your
chart by getting a copy at each visit. Then if you must change primarys
you'll have the documentations from before to just continue. It must be
consecutive not missing a month between. some insurance require nothing,
others 3 mo., 6 mo., 12 mo. or longer. It's the first hurdle to get over.
Unless you go "Self-Pay"" then go see your Bariactric
Surgeon!
— Michael Eak
August 29, 2006
http://www.morbidobesitysurgery.com - I have my first visit with this
surgeon tomorrow.
— beautifulsoul2877
August 29, 2006
I agree with calling your insurance company. They will give you the exact
criterium that they require. And even though a lot of people are telling
you your PCP doesn't sound weight loss friendly, he may kind of be right.
I submitted to my insurance company without the diet requirement that they
had and they denied it. So right now I have to go to monthly weigh ins,
the nutritionist, the gym and behavior modification therapy. And I have to
do that for months. And there are some insurance companies with more
requirements than that. And even if it it is 6 months, even if it is a
year...it's not forever. It's not the best feeling, but it may be what you
have to do. Look at it as an opportunity to help your body heal after
surgery. Good luck.
— jenw82
August 29, 2006
Ellen, have you contacted your insurance company? You should either go
online or phone and ask for their clinical guidelines for surgery. This
will tell you exactly what your insurance ompany requires of you in order
to pay for the surgery. I had to go on a doctor-documented diet for six
months, in spite of already having been on diets for years, since i was an
insulin-dependent diabetic. I also had to have my sleep apnea evaluated,
my cardiac health evaluated by a cardiologist, and a psychological test
done. (This way, my comorbidities were documented. i also saw an exercise
physiologist and had that evaluated. Meanwhile, I wwent to the surgeon and
got my date for the surgery for seven months from them, so that I could
have the surgery approved upon completing the requirements. I did not get
the requirements done and then go to the surgeon, but did them
concurrently. The insurance company just wants to know that you have tried
conventional methods for losing weight.
Good luck.
— Novashannon
August 29, 2006
Dear Ellen, I am somewhat older than you and didn't have time to fool
around either....so I borrowed money off my credit card, they are always
offering 0% financing for several monthes, and I had mine done in Florida.
There are some drs. who will help with self pay patients, too. Another
reason I think they want you to give it some time, this is a major life
changing desision, and I think they want to make sure you won'r regret your
choice. I hope this helps. I had mine done in Jan of06 and do not regret
it.
— sunbrat
August 29, 2006
Guess what ?? It really doesnt matter what your PCP says. When it comes
down to it, it is up to your bariatric surgeon and your insurance company.
Due to your recent health problems I would say that WLS is very neccessary.
Good luck to you and dont give up!!
— shannonwaycott
August 29, 2006
hi there! All good things come in time... it took me a year and a half to
get through all of the steps to healthiness! Call your insurance
beforehand to find out what they need to approve you. Mine had a
stipulation that I had to go to a pcp to do my six month weight loss diet,
not a doc who does bariatric surgery. This I found out, after going to the
surgeon for six months of dieting... Once I had the pcp document my diet
for six months, I was approved in less than a week! I had my surgery on
April 7th of this year, and am down 73 pounds and going! Good luck!
— earthangel
August 29, 2006
First thing you need to do is contact your insurance company to see if this
is a covered benefit, or if it's a specific exclusion. If it's NOT listed
as a specific exclusion, and not listed as a benefit then you have a
fighting chance to get it through with appeals. At this point, I wouldn't
worry too much about the insurance part of it as plans change all the time
and that more and more are approving this procedure every day. The next
thing I'd do is make an appointment to meet with a Bariatric Surgeon in
your area. He/She will have the answers to the questions you have and can
help you with the insurance as well.
Also you can check on this site to see what others have said about Personal
Care and their experiences.
If you want this bad enough, you will find a way to do it. You have to want
to make these changes and make yourself healthy, then use that as your
drive and determination to make it come true.
Good luck!
— oceanrayne
August 29, 2006
I went to Barix in Belvidere Il and they handled all insurance stuff for
me. I was approved very quickly. I did not ask for or need my PCP's
approval, Barix has their own internal med Dr who checks you out. Very
convenient, and a full program in place. they give you all the tools you
need to succeed if you just use them.
HUGS and good luck. I had surgery at 42 and wish I could have done it in my
20's like you. I would have had a very different life.
Oh well, Imourn the years I lost to morbid obesity, but life goes on and I
am having a good time now.
— **willow**
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