Question:
PCP wants more reasons for WLS

Ok so here goes. My PCP has agreed to put in the referral for WLS to Tricare. I called at the end of the week to check the status of it because they have a good turnaround time I have heard in my section. Even they said about 72 hours they will approve or deny. Well they did get anything. I told Tricare I saw him put it in the computer. I was told that he needs to fax it in. So I call to get another apt with my PCP and I find out he is not longer with the hospital anymore. UGH!!!! My new PCP wants me to have a list of all my weight related issues before he will consider a referral. I can only think of two. My fatty liver and the fact that I need to buy more clothes about every 2-3 months. I am stumped. I am so flaming mad that my brain will not switch on. I KNOW there are more reasons on why I should have WLS other than those two. I already qualify as far as weight and BMI but this PCP is a little up tight I think. I would change but it is like pulling teeth for changing them over here. I scheduled a meeting with my surgeon for OCT 5 but tht was almost 3 weeks ago becuase it was a "shoe in" to have approval by then. Any and all help is appreciated.    — Ginah Clark (posted on September 26, 2006)

September 26, 2006
Hi Kulita, First of all stay calm. You have to take this one step at a time, there is still a few days left before you meet with your surgeon. If you can't get approval by then, then still go to your appointment with the surgeon and see what he/she suggests you do. I have a question for you: Have you been diagnosed with any of the following conditions(other than your fatty liver)? -Heart Disease( including CHF, aterchloreosis(sp?), etc) -Diabetes -Insulin Resistance(abnormal glucose tolerance) -dyslipidemia(High Cholesterol) -High Blood Pressure -Sleep apnea -degenerative joint diseases( such as arthritis), etc. - any back, joint , foot pain that you feel may be associated with your weight. If you have any or all of these problems, then these could be very helpful for your new PCP to know because these are all "co-morbidities" of Obesity. Your new PCP only wants the best for you and that is probably why he/she is so hesitant about doing this for you. Also you may want to tell your new PCP any of the daily limitations that obesity inhibits you from doing( such as bathing, tying shoes, personal hygiene(you know what I mean! Sorry to be graphic!) etc. You should also tell your new PCP what weight loss programs( such as exercise programs, weight watchers, curves, etc.) you have been. Make sure that you document all of this too in your letter to Tricare(Sinced it hasen't been sent in yet because of your former PCP leaving). Insurance companies are very picky and want to know everything about you and all the things that you have been through to lose weight before. They may even require you to do a 6 month supervised diet before giving you approval so be prepared. I haven't applied for approval from my insurance company yet, but through EXTENSIVE research of this surgery, I know most things that pertain to getting approval and expect that my journey will be fairly easy. I hope that this helps you with getting approval and wish you the best of luck.
   — C. Reed

September 26, 2006
Hey there, You have come to the right place, I'm sure you will get a lot of good answers here. PCP's can be a real pain sometimes. Just sit down and make a list of all the weight related issues that you have even if they are small issues write them down. but first and foremost your reason should be because you want to be HEALTHY! I am just starting out and have had to cacel my consult with my Dr. because I smoke (not any more) and he wont see you unless you have quit for 3 months, so I know how discourgaing things can get at times... Anyway just try to think of anything you can write it down and take it to your PCP. don't get frustrated...I wish you lots of luck..Donna
   — [Deactivated Member]

September 26, 2006
First Step: Call Tricare and find out EXACTLY who your new PCP is. NOT who you can actually get an appointment with at your clinic, but the ACTUAL provider. If your referral letter and such comes from someone other than your PCP, Tricare will kick it back denied. (This happened to me, that is why I know. LOL!) Secondly, bring your original letter to your doctors appointment with your new PCP. I went to your profile and read it and it sounds like most of your "reasons" are documented in that letter. If you have any "evidence" of failing any other weight loss programs bring that too. I brought my books from WW and my stuff from every military program that I failed and that alone helped to convince my doctor! LOL! Think outside of the box when approaching Tricare... there are quite a few "conditions" that they consider when approving folks for WLS. Documented medical conditions like your PCOS, fatty liver, etc.... family medical history, high blood pressure, swelling of limbs, asthma, sleep apnea, loss of sex drive (yes, seriously in legal terms it's called "loss of consortium" in medical terms its loss of libido), uncontrolled stress, depression, hormonal issues, you name it.... go back through your records, ANYTHING that could be caused or complicated by weight gain can be considered a factor. Also, by Tricare standards your BMI qualifies you if you have at least 2 co-morbidities. If you have a BMI over 40, that is the sole approving factor. (At least that was the standards when I was approved!) I also noticed that you wanted the DS. As far as I know the only procedures that Tricare approves is Open and Lap RNY. That might have changed recently, but the last time I checked RNY was the only approved surgery. Since you do have Tricare, I assume that you are a military dependant, if so have you considered allowing a military surgeon perform the surgery? I chose to have mine done "on post" and had no problems getting approved and receiving my after care. HTH!
   — MagickalMom

September 26, 2006
Keep your appointment with the surgeon. The office where your previous PCP worked should still have your files. See if they still have the files and have them fax to the insurance company. You may not need the blessings of this new PCP. Some of them can be so anal retentive. If your company is due for changing or updating your insurance, may I suggest that you go with a PPO until after you've had the surgery. This way you want have to deal with a lot of referrals and a PCP. Check your state laws around morbid obesity treatment -- some are making it mandatory that insurance companies cover this surgery. It's mandatory here in Maryland especially if you meet the NIH standards.
   — the7thdean

October 2, 2006
Dol you have anything like high blood pressure, diabetes, or sleep apnea?
   — Novashannon