- Username: Jeila
- Location: DS Wantabe in..., GA, USA
- Member Since: 4/10/2008
- BMI: 53.9
- Consult w/Surgeon Completed
- Surgery Type: Duodenal Switch
- Surgeon: Dennis C. Smith Jr. M.D.
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"I want you to live forever, Mom"  Quote from my 14year old son!
Letter to CIGNA to be submitted with Medical Necessity on September 14, 2008 2:25 pm
Thank you for taking the time to review my request and discussing this request with my PCP Dr. Dinee Riley. I understand the request has been declined due to the impression that Dr Edward Lin with Emory Bariatric Center performs the Biliopancreatic Diversion with Duodenal Switch (BPD/DS). I have made attempts to set up an appointment with Dr Lin for this procedure and have been told he does not do this procedure for weight loss. Emory Bariatric Center’s website states the bariatric procedures performed at Emory are the Lap Band System, Gastric Bypass and Sleeve Gastrectomy. Multiple other online references also confirm this. http://www.emoryhealthcare.org/departments/bariatrics/services/surgical_services.html I assure you, I have contacted every CIGNA in-network bariatric surgeon in Georgia for the BPD/DS and was told by each office that this procedure was not done by their surgeon. I have also checked each of their websites along with researching for any indication of this procedure being performed by them. All with no results. It would take many months and many CIGNA dollars to set up an appointment with each surgeon to get written documentation that they do not do this procedure. As a CIGNA participant, I feel I have done due diligence to obtain this information and CIGNA could easily do the same.At This point, my options are to either go out of state to a CIGNA in-network bariatric BPD/DS surgeon or to continue attempts to get a local bariatric BPD/DS surgeon approved through the CIGNA Network Adequacy Program. Bariatric surgery is not just a procedure. It is a commitment to continued care through a Bariatric Program and a Bariatric support system. Having this procedure out of town would leave me without both. As with all surgical procedures, there is risk of complications and it would be in my best interest to be in the same town as my surgeon. According to CIGNA’s HealthCare Coverage Position (0051) revised 5/15/2008, the Biliopancreatic Diversion with Duodenal Switch is an approved bariatric surgical procedure for individuals with a BMI >50, when medical necessity criteria have been met. Once my clinical information has been reviewed for medical necessity, I will be approved for the above procedure as I meet all of CIGNA’s criteria. Making the decision to have major surgery to save my life has not been easy. After much research it is clear that the BPD/DS is the best procedure for me to achieve the greatest estimated weight loss, sustained long-term weight loss and eliminate or reduce my co-morbidities. Please refer to CIGNA’s Healthcare Coverage Position (0051) pages 11-13 for the studies that attest to the superiority of this procedure compared to other weight loss surgery. CIGNA’s Network Adequacy Program is for services that are not provided by a CIGNA provider within 50 miles of a participant. CIGNA is currently not providing me with an in-network provider for the services I need in the state of Georgia. I feel this clearly shows that I qualify for in-network benefits for Dr Dennis Smith to do the BPD/DS using the Network Adequacy Program. “Similar Services” are not the recommended procedure and I will not compromise what I know is best for me. As a health professional myself, I understand the difference in the WLS procedures and can make a well informed, intelligent decision on what I want and need for my own body and lifestyle. As you reviewed my CIGNA plan you learned I do not have out-of-network benefits for Bariatric Surgery. My plan does allow bariatric surgery and relies on CIGNA to provide the in-network providers to perform the CIGNA approved procedures. As you review my request for medical necessity, please reconsider my Network Adequacy Request. I look forward to hearing your decisions.
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Thanks Linny77 on August 30, 2008 4:49 pm
Key Lime Fluff
Instructions:
16-oz cream cheese, softened
1 large package Sugar-Free Lime Jell-O
2 packets Splenda
1/3 cup boiling water
1/3 cup cold water
1/2 cup heavy cream
1/2 teaspoon coconut extract
In a small bowl, whip the heavy cream with sweetener until peaks form. Set aside. While it is being whipped, bring water to boil. Mix the jello with 1/3 cup boiling water until all the gelatin has dissolved. Then, add cold water and stir. For the next step you need a big bowl with HIGH sides. Put gelatin in bowl. Slowly add in the softened cream cheese (add each 8-oz package in 4 chunks) and continue to beat with a mixer at slow speed. After all cream cheese is added, put in the coconut extract and beat at high speed until smooth. Then, carefully fold in the whipped cream. Use a spatula to scrape mixture into the pie pan and spread around. Sprinkle extra ground nuts, add a layer of whipped cream or a layer of meringue on top. Refrigerate several hours or overnight to allow Jell-O to set thoroughly.
1 carb, 5g protein per serving. WOOT!
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Thanks VAL on August 24, 2008 5:17 pm
Fabulous Recipes Again
Fabulous Ricotta Fluff Stuff
1 large container of ricotta cheese
1 box SF jello instant cheesecake pudding
dollop or two of sour cream (to taste)
A little bit of milk to lighten it up (about a cup-add last and gradually)
Mix it all up and enjoy however you want it. I love it with strawberries! It's a great fruit dip or just eating straight out of the bowl.
Fabulous Trail Mix
Base mix
1 jar peanuts
1 jar sunflower kernels
1/2 bag raisins or "berries and cherries"
1/2 small bag chocolate chips.
1 small bag macadamia pieces
1 small bag pecan halves
To this, I might add other nuts depending on what's on sale (walnuts, cashews, more pecans). I've also varied the fruit, too, so play around. Try to keep the proportions the same. It's so easy to load up the sweet stuff, but it's the nuts that are so valuable here. The balance makes the perfect sweet and salty snack and my daily breakfast. If proportions are kept, it's about 32g of protein for 8 oz.
Fabulous Custard -- full of protein, easy on new post-ops ~delicious!
3 cups milk
3/4 cup splenda
4-5 eggs (depending on size)
2 tsp vanilla
1/2 tsp nutmeg (optional)
handful of coconut (optional)
Preheat oven to 375'. Beat eggs, nutmeg and vanilla together in baking dish. On the stove, bring the milk and splenda just to a boil, then stir together to the eggs. Bake for 25 min
NOTE: when the milk is coming near to a boil, you'll get a little foam on the top. Remove this foam before stirring into the eggs, or it will get a weird texture on top.
God Bless Paula Deen for flourless peanut butter cookies!
1 cup peanut butter
1 egg
1 tbsp vanilla
1 cup Splenda
Mix and roll into balls (about walnut sized) and flatten with fork dipped in Splenda. Bake at 350 for 12 minutes.
TIPS
-Do NOT overocok -- they will get crumbly since there's no gluten
-Peanut butter is naturally low sugar - the low sugar kind only reduces it by 1g per serving.
-If you're picky about artificial sweeteners, I've done a 3/1 with splenda and sugar to cut the after taste and it's good. Presently, I do full-splenda in the cookies, and roll in regular sugar and that's good too. I've also added semi-sweet chocolate chips to shake things up.
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Bacon Cheeseburger Quiche on August 23, 2008 1:57 pm
Bacon Cheeseburger Quiche
Ingredients:
- 1 lb. very lean hamburger
- 1 small chopped onion
- 4 slices crisp-cooked bacon, chopped in bits
- 3 eggs
- 1/2 cup mayonnaise
- 1/2 cup half-n-half
- 8 oz. shredded chedder or swiss cheese
- garlic powder to taste (optional)
- white pepper
 Brown hamburger in skillet with onion. Remove and mix in bowl with bacon pieces, breaking up any larger clumps with a fork or pastry mixer until you have a fine mix. Drain well of any excess grease and press into the bottom of a deep-dish pie pan. Set aside.
Preheat oven to 350°F.
Combine remaining ingredients in mixer bowl and whip well. Pour mixture over beef "crust" and bake 40-45 minutes until top is browned and "set." Cool 15-20 minutes before slicing. This can be packaged in Ziplocs or plastic containers for meals quickly microwaved over the next 3-5 days. (Does not freeze well, though.)
Serves 6. 2 grams per serving. |
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Crabcakes on August 11, 2008 5:51 am
The crabcakes are SO easy and MUCH MUCH more affordable then out. I used a 16oz can of jumbo lump crab meat, 1 egg, 2 t. worchesire, 2T mayo, 1t mustard, 1 handful of finely shredded mozz cheese and a handful of breadcrumbs.....mix together and form into "cakes".....bake in the oven for 15+ minutes until golden brown and YUMMY!
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Archive
My Story My Timeline:
03/21/2008 - Started researching WLS.
04/05/2008 - Faxed paperwork to Dr Champion for Lapband. Still lurking on OH
04/07/2008 - Informed by Champions office of insurance requirements.
04/10/2008 - Joined OH... What an awesome help.
04/11/2008 - Informed PCP of plan for lapband. Will start 6mo SDP from Dec.
04/14/2008 - Faxed paperwork to Dr Macik who is in-network. Less $$$$
04/15/2008 - Made appoint for stress test, Echo, PFT, Sleep Studay & Dietician.
04/16/2008 - Heard from Maciks office. Will go forward with him.
04/19/2008 - No Sodas for about a week. Easier then I thought.
04/20/2008 - Learning more about VSG. Less maintance then LapBand.
04/24/2008 - Learned Cigna does NOT cover VSG or DS. Will work on self pay.
04/24/2008 - Completed Stress test, Echo and PFT. All looks good.
05/05/2008 - Saw Dietician. Doesn't know much about WLS Diet. Just listened.
05/08/2008 - Recieved self pay VSG quote from Alvarez in Mexico. Reasonable
05/09/2008 - Cancelled sleep study for now. Out of pocket just to much. Will reschedule if needed.
05/11/2008 - Recieved self pay VSG quote from Macik and Champion. Both way to much.
05/12/2008 - Told PCP about plans to self pay VSG. Possible in Mexico.
05/13/2008 - Made appoint for Dr Smith seminar to get self pay VSG quote.
05/16/2008 - Went to Dr Smith seminar to get self pay VSG Quote. Reasonable.
05/22/2008 - In completing Dr Smith paperwork Learned Cigna now covers DS for BMI >50. My policy only covers in-network bariatic surgery. Contacted all Surgeons and none of them do the DS. Made appointment to talk to Macik.
05/23/2008 - Researched out of state in-network surgeons. Closest is Dr Spaw in TN who does open.
05/27/2008 - Spoke at lenght with Dr Spaw. He will accept me into his program for DS.
05/28/2008 - Paperwork submitted to Dr Spaw office.
06/02/2008 - Cancelled Dr Macik. He does not do the DS.
06/07/2008 - Want to have DS with Dr Smith in GA. Not out of State. Will talk to Cigna after vacation.
06/16/2008 - Requested advise from Dee on Getting Dr Smith approved.
06/17/2008 - Learned from Cigna about Network Adequacy Program. Will persue approval.
06/23/2008 - Informed PCP of plan to have DS by Dr Smith in GA. Requested letters to submit.
06/23/2008 - Notified oncologist of plan to have DS. He is on board and will write letter if needed.
06/24/2008 - Cancelled 2nd Dietician appointment. Will see Dr Smiths Nutritionist.
06/26/2008 - Informed Smith's office Dee of Cigna Network Adequacy Program. She will call them.
06/30/2008 - Informed by Dee that Cigna has opened a case and is awaiting Letters of request.
06/30/2008 - Emailed PCP letter to sign recommending DS WLS.
07/02/2008 - Recieved sign letter from PCP and 6mo SDP letter.
07/03/2008 - Dee submitted Letters to Cigna for Out of network to in network approval for Dr Smith.
07/08/2008 - Dee talked to Cigna, Hope. They received the paperwork yesterday and are now reviewing. 07/14/2008 - Talked to Cigna and Dee. Cigna DENIED inital request. We sent what they requested and now they want more. Will set up Appointment with Dr Smith to get all clinical stuff done.
07/14/2008 - Emailed Dr Schweitzer in Maryland to inquire about that WLS program.
07/15/2008 - Appointment made with Dee for 8/12 and Dr Smith on 9/12.
07/16/2008 - Received email from Dr Schweitzer, requesting I set up a consult. Hmmm? Not quite yet.
07/25/2008 - Inquired with Cigna regarding denial. Was informed to set up Peer to Peer with PCP.
08/06/2008 - Saw Dr Riley, gave her an update and requested Peer to Peer review with Cigna.
08/12/2008 - Met with Dee at Dr. Smiths. Received pre op instructions. Requesting Oncology clearance and ERCP in addition to cardiac & pulmonary clearance, dietician and psych.
08/12/2008 - Rescheduled appointment with Dr Smith for 8/27. YEAH
08/15/2008 - Saw Dr Sarma and got Oncology Clearence. Ordered Chest/Abd CT
08/15/2008 - Met with Dr Smiths Dietician.
08/15/2008 - Contacted Cigna. Was informed request was still denied after Peer to Peer review.
08/15/2008 - Set up appointments - cardiology, CT scan, and psych eval.
08/20/2008 - Received Cardiac Clearance from Dr Kahn.
08/21/2008 - Had CT Scan
08/21/2008 - Had Psych evaluation
08/22/2008 - Met with Dr Riley, Confirmed Cigna still denies request. Was told to check with Dr Lin at Emory. Requested PCP letters to be faxed to Dr Smith along with all test results.
08/22/2008 - Set up appointments for GI, Pulmonary, EKG and labs.
08/22/2008 - Contacted Dr Lin's office, confirmed he does not do the DS.
08/25/2008 - Contacted Dr Lin again, was again told he does not do the DS. Composed letter to Cigna.
08/26/2008 - Had Repeat EKG and Labs drawn.
08/27/2008 - Had consult with Dr Smith. He agrees with DS for me. Gave Dee my letter to Cigna to submit.
08/29/2008 - Saw GI Dr Adeniji, he is recommending MRCP instead of ERCP.
09/08/2008 - Woke with Vertigo. Rescheduled pulmonary to 9/15.
09/10/2008 - Spoke to Julia at Dr Smiths office. She is waiting for PCP letters to submit everything to Cigna. She has also not recieved Cardiac Clearance or CT Scan.
09/11/2008 - Went for MRCP. Had large thing straped to abdomen and I could not breath in MRI tube.
09/11/2008 - Inquired with Dr Riley's office on status of PCP letters.
09/12/2008 - Spoke with Dr Rileys office, she will have the letters ready by Monday.
09/12/2008 - Requested cardiac clearance from Kahns office and CT scan from Sarma, to be faxed to Smith.
09/12/2008 - Emailed Julia, informed her to expect faxes today and monday. Informed her about unable to have MRCP and requested she inform Dr Smith to see if he still wants ERCP. Also requested copy of labs.
09/15/2008 - Saw pulmonologist. Sleep Study set up for this Sunday 9/21.
09/15/2008 - Confirmed with Julia they have received PCP letter. They will review my chart with Dr Smith tomorrow.
My story is no different then the many living the life of obesity:
....... struggled my whole life
....... tryed everything
....... yoyo
....... gain more back
....... love food
....... hate veggies
....... poor health
Now at 49, I have moved from "Regular Big" to "Extra Big".  Super Morbid Obese.... who knew, YEP thats me. Breast Cancer 5yrs ago didn't help. I felt better on Chemo by eating.... wouldn't you know it, most people can't eat on Chemo. There's another 30lbs. Then I developed lymphedema due to my cancer surgery and radiation. Lymphedema affected my mobility. Lost my run around job and got a desk job........ there's another 30lbs. Current meds.... add another 20lbs. TADA that makes me 330lbs. WHEW, I promised myself I would never get this big.
I found a great new PCP who whipped me up on labs and test. WOW, time to get out of denial land. Have had high BP for 7yrs, now boarderline diabetes, high cholesterol & fatty liver infiltrates.
Will start insurance requirements and hope to have surgery soon!!!!!!
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