ObesityHelp

MY GROWING LIST OF CO-MORBIDITIES


hypertension
high cholesterol & triglycerides
chronic neck pain - 3 bulging discs
" shoulder "
" back " - bulging disc
" hip "
" knee "
" foot "
" leg pain & numbness
depression
headaches
fatigue
poor sleep
lower extremity pitting edema
hypothyroidism
stress incontinence
carpal tunnel syndrome
rashes
gastric reflux
gallstones
torn meniscus
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2-13-04
BMI 41
co-morbidities: hypertension (on medication), high cholesterol & triglycerides (on medication), chronic neck, shoulder, back, hip, knee, foot pain, depression (on medication), hypothyroidism (on medication), gastric reflux

I've been undergoing lots of tests with my PCP before he writes a referral for a bariatric surgeon. So far, I don't have sleep apnea, although the report stated that I didn't sleep well - DUH! - does anyone sleep well with all of those wires, belts, etc? My cholesterol & triglycerides are both close to 300. The treadmill part of the stress echo cardiogram was normal, we're waiting for the echo part to be read. This afternoon, the "nurse person" in my PCP's office called & said I have gallstones & I'll have to have my GB removed before I have gastric bypass. I asked why I couldn't have the surgeries together, & she didn't know. I'll have to wait until next week to see the doctor & ask him. My last test is Monday - venous studies on my legs to make sure there are no clots (my left calf has been hurting for 2 weeks). Hopefully next week I'll have a referral letter to go see a surgeon. Now if Cigna will just okay the surgeon I want.
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2-26-04
BMI 41

FINALLY I got the OK to schedule an appointment with the surgeon. He can see me this Monday!!!!!!!!!!!!!!!!!!

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3-3-04

I had my consult w/the surgeon, Dr. O'Connell. I'm very confident with him. He said Cigna's hard to deal with & before he submits my request he wants a letter from my PCP including info on my 6 month PCP supervised weight loss attempt last year. I wrote a 3 page letter for my PCP to copy to his letterhead & I have an appointment with him (PCP) tomorrow. Once he's approved it, I'll post a copy of it here. I'm also going do write a letter from ME to send to Cigna too. I trying to speed things along before my gallbladder attacks me again. It needs to come out very soon & I don't want to have surgery twice.
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3-4-04

Saw PCP today. He "really hasn't had time to read the letter yet, come & pick it up on Monday". Oh well, I didn't have my letter to Cigna ready yet anyway. Now I'll have the weekend to finish it.
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3-12-04

FINALLY! My PCP letter is ready. He only made minor changes to it. A copy is near the end of my profile.
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3-15-04

Cigna says my case is "pending nurse review"
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3-16-04

Cigna says my case isn't showing.....it was in the wrong department. Rhonda w/Cigna is sending everything to the pre-cert department.
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3-18-04

Cigna says my case is "pending nurse review". I called again later and it was in medical director review & they will decide between now & Monday.
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3-19-04

DENIED sometime on 3/18...it took 2 phone calls to find out why - something about my med. sup. diet - which I did!!! When Dr. O'Connell's office gets the letter, Heather will do the appeal.
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3-31-04

Well, I've been going nuts lately. Mostly depressed because I wanted to get approved so I could go ahead & have my gallbladder out - which speaks to me daily. My nerves have been shot because I'm so worried I'll have another GB attack - if this happens, I'll have to get it out right away. I know I'll eventually get approved for WLS, and I want to do both surgeries at the same time.

Cigna denied me because they say I didn't do the 6-month physician monitored diet... Well, I did. Last March, I went to my PCP because I wanted his help to lose weight, I wanted Meridia & Xenical, I wanted to see a nutritionist, I told him I was going to go to counseling, & that I was exercising like crazy. When I did this, I wasn't even THINKING WLS, if I had been, I would have made sure that I was in his office every 30 days, weighed, and stood over his shoulder while he documented everything.

I've decided to get help with writing an appeal letter from me, to be turned in with the PCP's & surgeon's letters, and a report from the social worker I saw last year. I have to get lots of papers together to give to my "ghost writer".

I've just realized this week that we never received a benefits book when we switched to Cigna HMO this year. My husband signed us up at open enrollment back in Oct or Nov '03, and the Cigna guy had run out of the books. I called Cigna this week, but they can't send me one, I have to get it from HR. But Cigna CAN send me a provider directory. Talked to the lady in HR today, and she couldn't believe that Cigna wouldn't/couldn't send it to me. She said she'd try, but no guarantees because she doesn't actually handle insurance matters, that's handled by the benefits office in Houston & she gave me their # & told me to tell them about my problems w/Cigna (she said this is also the # to speak to someone about my denial). She called back to let me know what a run around she got!!! Whomever she spoke w/at Cigna was rude to her. I'm planning to call them tomorrow about the book, and while I'm on the phone I'm going to mention the denial. I wasn't going to call them about it until after my appeal, but since I have to anyway...
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5-17-04

Well - last week I FINALLY got the benefits booklet from Cigna - after lots of phone calls.

After my denial in March, I immediately called Cigna & requested copies of all of the documents they used to determine my claim - FINALLY got it last week. And guess what - my PCP's 3 page letter isn't even in there. So it seems that they made their determination without any information from him.

Found out today that the severe pain & swelling I've been having in my right knee for the past 5-6 weeks is caused by a meniscal tear (shown on MRI). Because of my symptoms, the ortho doc recommends surgery to remove the torn fragments. Since the Celebrex he gave me is helping, I want to put off surgery until after my eventual WLS.

Update on my appeal - I need to get records/letters from my neurologist & now orthopedic surgeon & send these to Roberta so she can write my appeal letter. All of this takes SOOOOOOO long & the longer it takes, the more depressed I become. And I've recently changed anti-depressants, so I guess the old brain is having trouble adjusting.

Oh - another update - my cholesterol is normal now - thanks to Lipitor, however, the triglyceride level went up even more, so now I've had to add another prescription to try to lower it. Now my SIX - 6 6 6 - monthly prescriptions are right at $200 a month - my co-pays - I wonder how much the retail is - I'll have to ask the next time I get them filled. Doesn't Cigna get it??????? Prolonging WLS is only causing more problems and costing more money. Not to mention what it's doing to my physical & mental health.

5-19-2004

I've been so depressed today. Last night, I bent over to pick up a toy or clothes or something one of the kids left on the floor, & I couldn't get up. My back was about to kill me! I grabbed the counter & gradually made my way somewhat upright. It's still hurting so bad. I've doubled my Celebrex & I've taken a couple of Darvocets today so I can move. I look pathetic walking: limp because my right knee hurts, then limp the other way because when I put my left foot down my back & left hip & butt cheek hurt. Since around October I've been quickly falling apart. This time last year I was fat & healthy. I'm going back & forth on knee surgery: do I have it now & heal before WLS so I'll be able to exercise, or do I wait for WLS and then do the knee surgery after I lose weight? To make things worse, since my depression has been worse, I've been eating more & I think I've gained another couple of pounds.

5-21-2004

After speaking with my PCP today, I've decided to go ahead & have the knee arthroscopy done to repair the torn meniscus. I'll call Monday to schedule it within the next 2 weeks. The pain is really limiting what I can do & probably increasing my depression. The ortho doc will want me to stay "flat on your back" for 3 days, I wonder if sitting on the couch will count??? Maybe I can get my DH to take the kids somewhere for a few days & have my Mom come over & wait on me. I could watch TV, read...3 days doesn't sound like enough.

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March 2, 2004

Cigna Health Care
Health Services
_____________________
_____________________

Health Services Fax # 1-800-________________

RE: (NAME)
ID # __________
SSN ___________
DOB __________
Account # ______

REQUEST FOR EXPEDITED APPROVAL FOR GASTRIC BYPASS

This letter is to serve as documentation of medical necessity for surgical treatment and associated medical care for the treatment of morbid obesity as outlined below. I serve as the primary care physician for ___________, a ____-year-old Caucasian female who suffers from severe obesity. Her current weight is ____ pounds, height _______. This calculates to a body mass index of _______.

In addition to severe obesity, - _________ also suffers from co-morbid conditions including hypertension, hypothyroidism, depression, stress incontinence, GERD, chronic leg pain & numbness, chronic pain to the knees, hips, feet and heels, bilateral carpal tunnel syndrome, very large breasts that cause back, neck & shoulder pain, rashes under the breasts, frequent headaches, and pitting edema to her lower extremities. She also has a bulging disc in her cervical spine, which also adds to the pain she experiences in her neck, shoulders, and into her right arm and hand. Recent blood work revealed elevated cholesterol (_____) and triglyceride (____) levels. Although she does not have sleep apnea, she does not sleep well due to her snoring and multiple pains, and this causes her much fatigue. These co-morbid conditions are directly related to her obesity.

A recent ultrasound of her gallbladder showed the presence of stones, and the patient has had two episodes of possible cholecystitis, which at the time she believed were severe symptoms of GERD (these episodes occurred before the gallbladder ultrasound). Because of the cholelithiasis and the great probability of _________ developing cholecystitis, she needs to have surgery as soon as possible to remove this diseased organ. She wants to have this surgery at the same time as the gastric bypass procedure to avoid undergoing general anesthesia twice and also to avoid two hospitalizations and recovery periods. For this reason, expedited approval is necessary.

_____________’s current medications include _____________________. She also takes vitamins.

____________ reports that she has a difficult time performing ordinary activities such as standing for long periods (i.e. standing while cooking), doing laundry, housecleaning, shopping and caring for her two small children. Her obesity has also made it very uncomfortable for her to exercise, and she reports that caring for her own personal hygiene is becoming difficult.

Her family history is significant for breast cancer, colon cancer, stroke, heart disease, hypertension, hypothyroidism, depression, kidney disease, obesity and arthritis. Her mother had breast cancer at age 48, and her paternal grandfather died of colon cancer. Her mother is morbidly obese.

The patient has already employed several weight loss measures unsuccessfully. These include home dietary regimens, Weight Watchers, Jenny Craig, Sugar Busters diet, Weigh Down Workshop, Light Weigh Workshop, low calorie, low fat, low carbohydrate, fasting, Richard Simmons, Hollywood diet, The Zone, subliminal tapes, hypnosis, Slimfast, Herbal Life, Overeaters Anonymous, over-the-counter diet pills, medically supervised weight loss, hypnosis, and prescription weight loss medications all in conjunction with aerobic exercise.

In March 2003, _____________ presented in my office with the request for assistance in her efforts to lose weight. She was prescribed Meridia and Xenical, she requested and had a consultation with a registered dietitian and was placed on a low calorie, low fat diet. She participated in aerobic exercise and weight resistant exercise approximately 4-5 times a week at a health club. She also walked at other times, and even started jogging. She did lose some weight, and after six months decided to stop the Meridia and Xenical to see how she could do without the medications. The weight started returning despite her exercise and diet efforts, and she soon developed hypertension.
Despite the fact that she has indeed lost some weight in the past from her weight loss efforts, she has always regained it with additional pounds added each time, and her weight still remains significantly elevated as noted above.

From the success rate derived from gastric bypass surgery and health benefits involved, I feel this would be the best solution for permanent weight loss. I am recommending surgical intervention for the treatment of morbid obesity in this patient, which may include gastric bypass surgery. It has been proven that surgical intervention for obesity in cases of refractory morbid obesity is the most effective and long-lasting weight loss measure available. If obesity is not corrected in this patient, significant co-morbid conditions will continue to worsen, further declining her health and others may develop. I also believe that many of her health problems would be ameliorated by such an intervention and permanent weight loss would greatly improve her future health and quality of life.

I trust this information will aid you in understanding the true severity of __________’s case and in facilitating the proper assessment. Please feel free to contact me if I can answer or clarify any questions you might have.

Respectfully Submitted,


____________________
__________________MD


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QUESTIONS TO ASK YOUR SURGEON

1. Are you listed with the ASBS?
2. Board certifications? Which?
3. How many surgeries have you performed? open/lap? # or % of complications? What % of your practice is bariatrics?
4. What is your most common complication? Require more surgery?
5. Mortality rate?
6. Do you offer more than one type of procedure?
7. What is the difference?
8. What type of surgery do you think is best for me? Proximal or distal for me?
9. What additional pre-op testing will I need?
10. What is the long term success rate of your patients who have had this particular kind of surgery?
11. How many days will I be in the hospital? ICU?
12. What kind of pain will I be in?
13.How long is the recovery?
14.What do you do for prevention of DVT?
15.When can I return to my regular activities (housework, small children)? Shower/Bathe? Drive? Sex? Exercise? Weight train? Water aerobics?
16.What about the support group? When does it meet?
17.Can I get a copy of the post-op sample diet?
18.How soon can we schedule surgery? Can I choose a specific date?
19.How many follow up appointments will I need? When?
20.What can I do to prepare myself for surgery and be successful with as easy recovery as possible (mentally, physically)?
21. Is my husband allowed in the recovery room?
a. Can he spend the night if I am in a regular room?
22. Does the hospital have a Weight Loss Surgery unit?
23. How long will I be in surgery? GB & Chole.
24. Do you visit my family after the surgery to tell them how it went?
25. Reasons the surgery may not happen after you open me?
26. How long is the average recovery time for open surgery?
27. I know I have gallstones, how will you check for stones in the bile duct?
28. Do you handle pain management or does the ansthesiologist? What types of pain management is provided
a. at the hospital?
b. at home?
29. Where is the nearest support group to me?
a. Contact Info?
30. Will I have an opportunity to meet with the anesthesiologist before surgery?
a. Does he/she have experience with obese patients?
31. What’s the possibility that I will I be on a ventilator?
32. Will I have an NG tube?
33. Will I need a catheter?
34. Will I have drainage tubes in my incision?
a. How many?
b. For how long?
35. Do they have gowns large enough for me?
36. Will I need a binder? Will it be provided by the hospital?
37. How can I combat hair loss?
38. What do you recommend to avoid vitamin deficiencies?
* multi-vitamin ________________
* calcium citrate _______________
* B-12 ___________________ PO SL
* fish oil ? _______________
* ___________ grams of protein
* ________________________ other
39. How can I avoid vomiting? Dumping?
40. What is your recommended menu for the first few months post op?
a. Clear Liquids, what kind and for how long?
b. Full Liquids, what kind and for how long?
c. Pureed Foods, what kind and for how long?
d. Real Soft Foods, what kind and for how long?
41. When will I be able to take aspirin or Advil?
42. What else will I need to avoid? Do you have a list of these things printed up?
43. What if I lose weight before surgery & BMI drops?



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