Question:
Whats next? please please please help!
hi everyone, im new to the post, my situation is this..last year I applied for WLS through medicaid and was denied. My PCP did not think that WLS was the way to go, she wants everyone to do diet and exercise till they are a size 6. Well I did not know this until after i was denied. I switched doctors and am now seeing fnp foster-weiss. she is wonderful, thought i still have not popped the WLS question to her I have been letting her know about my struggle. I also have medicare now as well as medicaid. I am going in for a sleep study tomorrow and am going to quit smoking with my doctors help in 2 weeks. I have diabetes,asthema, pain everywhere, skin problems and other things wrong due to my weight. i am 4'11" and weight about 215. i think that makes my bmi a little over 42. I am 22 years old and want to have a healthy life, i want children one day and also want to be able to do normal day to day things without being "weighed down" What would you say would be my next step for getting the surgery? thank you all — Shelly M. (posted on February 19, 2006)
February 18, 2006
You may have been denied thru MedeCAID but MediCARE covers WKS. So you
have coverage! You can find the coverage requirements on the medicare
website. Obvisouly if you are 22 with BOTH you have medical conditions -
I would talk to your PCP or start calling around to surgeons in your area
that take your insurance (MediCARE) and talk to someone handling their
programs.
— star .
February 18, 2006
Hi Diane, I was where you are a little over two years ago. My suggestion to
you is to get in touch with a Gastric ByPass Surgeon. Set up an Appt. and
let him/her determine if you are eligiable for the surgery. That is what I
did. I am also on Medicare. Medicare does not give approval up front. You
have the surgery first then Medicare pays. That is why you HAVE to go to
the Surgeon to see if the Surgeon thinks you are a good candidate for WLS.
With you BMI as high as it is you are in the range for eligiblity. Have you
gone to the BMI charts ?? I am 5 foot tall and I was 211, my BMI was 42, I
was wearing size 22/24 now, 2 years after surgery, I am still of course 5'
tall but my weight is 115, my BMI is 22, I believe and I wear size 2...Go
find your Surgeon. Don't wait for you Primary Doctor to say it is OK, it is
not his/her body or life. It is yours, just do it!!! Good luck and email me
if you'd like. Read my profile.
Cindy
— cindirella
February 19, 2006
Hi Diana, get ready to do some paperwork and research. My surgery was paid
for by my Medicare and QMB Mediciad 100%. I had to ask a lot of questions,
and find just the right doctors that would take Medicare, and were familiar
with it. For a surgeon, Medicare can give you a list of who they cover in
your area. Call all of them until you find one that suits you best. The
very first step is to get your doctor to say that it is medically
necessary. Good luck to you!
— ninoid
February 19, 2006
ive been saving your advie and will use it, thank you all for being so
supportive and helpful. I will be searching previous posts and websites to
do my research. when i write my letter, is it ok to speak of my personal
experiences day to day or should i stick to medical terms when telling my
insurance company and the surgeon i choose about whats going on?
— Shelly M.
February 19, 2006
your profile is empty, all that you are presenting is that you are 22 years
old,on welfare,obese, very poor health and on medicare about 43 years
early, not much to offer advice about, tell us more. got any education? had
a job? work experience?
— walter A.
February 19, 2006
Oh, Walter...*tisk_tisk* By Accident I've run into a few of your posts
this morning and I'm ashamed of how you reply to these Q&A's.
Anywho, I think the previous answers above were very helpful. You'll need
to do a bit of research and find a WLS friendly PCP and Surgeon who accepts
your Insurance coverage. I think poking around under the Insurers and
Peers section you should be able to find people that are in your area who
have WLS friendly PCP's.
Good Luck!
Tisha
— Tisha C.
February 19, 2006
I had a problem in the beginning finding a dr that would support my
decision for WLS. I found a seminar on WLS and lapband and attended. They
helped me find a dr that would give me the support i needed. I'm not sure
what state you live in but i found the seminar online. If you go to a dr
that specializes in WLS they know exactly what to do to and if you should
qualify for WLS. Sometimes it takes being submitted to the insurance
company <in your case MediCARE and/or MediCAID>. Some states, if
you have more then one medical condition due to obesity <IE: sleep
apnea; diabetes, hyper tension> it qualifies you. Also, some
"insurance companies" require that you follow some guidelines
that THEY have, not necessarily the dr. For instance, I had to have a
membership to some sort of exercise establishment for atleast 6 months, and
I had some tests that the dr didn't require but the insurance company did.
All in all, i think they should know how fast my hair grows by the time
they were done. It took me 18 months but they approved my sugery and I'm 6
weeks post op. Don't give up and be the biggest pain in the butt that you
can possibly make yourself. Show them that you WANT and NEED this surgery
and that you'll stick with it. Good luck!!!!!!!
Peace, Love and Light
— SlNsWithin
February 19, 2006
Ok well I wasnt aware that i had to get really personal in my profile , but
since some people insist on being rude because i havent been here goes... I
am 22 years old, i live at home due to a disability. I live with my
boyfriend of 4 years and our dogs and cats. If you would like a record of
my work expierience, I would like to know are you hiring disabled persons?
Those people who are are the only ones who need to know something so
personal. I am very well educated. I had once planned on teaching
English, however, until I get my physical self under control and well, i do
not plan on going back to school, some things are more important than
others. Right now it was a personal decision of mine to try to get better
so that i can get off of disability and get out into the real world, and
perhaps go back to school. Maybe I am on Medicare too early, my doctors
and my state do not seem to think so however. As for calling disabilty
welfare, thats a little harsh, I never asked to be disabled, I never asked
to have my life turned upside down and to not be able earn a living. I do
not understand how one can not answer the question that I posted above
unless they know these things. I thought this was a support group, people
helping people, not people trying to belittle people. If anyone would like
to help me ( and so many of you have been so helpful) please do so, but if
all you would like to do is pick at my situation than please do not post.
I have researched my PCP and apparently several people on this site see her
and she does support WLS! I have attended a siminar, I am just not sure if
i need to do anything else to get the process rolling, As for the diet,
will it help my chances if i start the diet now or when i get approved?
— Shelly M.
February 20, 2006
Diane, Don't worry about what Walter says, I looked at his profile and his
is nearly empty too and I have found that most men named Walter are
A--Ho-es.....I know, My husband's name is Walter as well as My
father-in-law and they are both *sshol*es................by the way..I have
been on Social Security Disability since I was 47 years old, there is no
set age for DISABILITY!!!!!
— cindirella
February 23, 2006
Hi Diana,
What Walter means is that your far too young at age 22 to basically have
your life all over. He is right 22 is far too young to not be able to take
care of yourself. Honestly he knew of your financial situation because in
order to be eligible for MEDICAID you're living below the poverty level and
this is common knowledge. Most states consider MEDICAID to be welfare.
You should approach your PCP about WLS, be prepared to have lots of tests
and jump through hoops, most insurances require 6+ months of a physician
supervised weight loss program. You may need to pay some of these costs out
of your own pocket. MEDICAID is different in every state, but not all
doctors and hospitals accept MEDICAID. You may have seen other posts on
this site from Medicare patients who have said that the surgeons require
up-front payment because Medicare doesn't pre-approve surgeries and may not
pay for them. Now as things are in hospitals, they don't take chances of
not getting paid for a $30,000. + surgery, in some hospitals if the claim
for payment is denied, the hospitals take the money for the operation out
of the surgeons own pocket, they might get paid well, but not well enough
to be paying for other people's surgery, so you could have trouble finding
a willing surgeon due to your finances.As for your disability issue, you
don't mention what it is ,but is it something caused by the weight or is it
totally unrelated? Do you think that by having WLS you will become not
disabled?
Your success with WLS and life is usually detirmined by your own efforts.
Life after WLS is damn hard work and anyone who tells you different in
wrong, relationships with people and food change, sometimes after WLS you
find out the hard way who your true friends and supporters are. Best of
Luck
— goldroses
Click Here to Return