I have 3 wonderful daughters and a wonderful husband and i feel if i dont lose my weight i will not be around to enjoy them im 38 yrs
I had my consultation on 9-28-02 The btc faxed all my paper work to cinga on 10-17-02. I called them on 10-22 they said they didnt show any approval yet. Called back on 10-29 they said they still hadnt so i asked if they had received the paper work yet and i was told they couldnt tell me that. My provider would have to call and find out. On 11-7 my husband called and they said still no sign of an approval, so he asked if they could tell him if they had received them yet, the lady got rude and said that they could not do that well he came back at her and she finally put him on hold and came back and told him that it was pending.Then on 11-8 i receive a letter requesting 3 more things Complete medical records for last 3-5 yrs. A psychological evalution. And a nutritional evalution. I have been back to my pcp for a referral to a nutrition and to get my medical records faxed to them. By the way my pcp is 100% behind me , he said he would do all he could. Now all im doing is waiting for the appoval the nutrition and the psychologist is doing her own to get approved and said she would call with an appt. when she received it. This waiting his what is so bad.
I got my nutritional referral approved and an appt. still waiting for the psch. one but at least i got one down.
I found out on the 17th that I am gonna be a grandma. My dughter dont want me to have surgery since she seen the dateline with Al Rokker and she saw that 1 out of 200 die. At first I was torn, but now i know if i dont i wont be able to enjoy my grandbaby. I had my nutrition elvaluation on the 19th, she says she will write that i do need this because it looks like i have tried every diet under the sun. Now all i got left to do is the phsy. eval., which i was told i would receive an appt. by next Tuesday.Then i have to sit and wait for them to get it and either approve or deny.
I just need to vent some here. I called to set up an appt for a psyc. eval. back on nov 7th. I was told it would be 3 weeks before she could get me an appt. and get ins. approved. Well I called this morning she still had not got ins approved and said she had me on waiting list for a cancellation. So she calls me back 10 mins later and says my ins wont approve that i have to go thru my husbands employee sponsored one. So i called to get that set up. I have to go talk to a woman for her to decide where they will send me for this. I still have not quit smoking yet I have doubled my smoking. Iam going to pcp today and tell him I need the patch if 2 meds didnt help I pray this will. I am also on ss for a back injury, hypoglycemia,heart mumur,and depression. They are rechecking to see if Im still considered disabled. So i have to go and have all the stuff done again that I just had done for this surgery. Why they cant just use what i just had done I will never understand. The only thing I dont have that they are requesting is the psyc.eval.
Ok I got my last eval. done. I ended up self paying though I am putting in here what all happen and why I ended up paying. Im also going to put a letter I decided to write to the ins. Actually Both are going to be sent.
December 12, 2002
To whom it concerns:
Im writing in regards to me wanting to have gastric bypass surgery. I will start by letting you know my reasons for this I am 38 years old. Im happily married to a wonderful man. I have 3 wonderful girls. I just found out I will be a grandmother in July. I have never really thought of myself as being thin. When I was a teenager I always weighed between 120 lbs and 150 lbs. When I got pregnant for my first child I weighed 138 lbs. When I had her I weighed 210 lbs. I was back down to 145 lbs within 7 months. I stayed around that weight until I hurt my back in 1984. I gained all the weight within 3 years of my injury. I have tried every diet from prescribed medicines to fasting and since I put on all this I have never been able to get less than 200 lbs. My current weight is 238. My highest was 271 lbs. Besides being depressed about my weight and all the pain I have a heart murmur, which Im afraid if I keep this weight on will give me trouble as I get older. I have hypoglycemia, which the doctor said will probably go to diabetic because both parents have it. I now have arthritis in my hands and knees. I know with this surgery my pain in my back and knee will lessen. I wont have as much fear in my heart giving out on me. And I probably will not end up with diabetes. My life would be so much more. As it is now I cant go shopping without having to sit down for awhile because of the pain. I will be able to be in more activities with my kids. I will be able to enjoy my grandbaby that we are expecting in July. My husband and kids will not have to sit and listen to me whine all the time about the pain. I just want to enjoy life instead of praying all the time to help me with the pain.
I am enclosing a copy of different people who have Cigna and how their claims were handled. I see a lot of inconsistent. It looks like to me it all depends on who get your claim and how they feel. They lose documents all the time. They request different things. Some have an approval within days, and others wait months. Then some have to appeal. It looks like to me that there would be a set standard. If this is going to improve anyones life. Why would they not approve and in a timely manner as I see it if they dont for me in the long run the cost for them to aid in my health will far out weigh the cost of this surgery.
December 12, 2002
To Whom It May Concern:
I was required to have a psychological evaluation in order to get approved for the gastric bypass surgery. So I got online and went to Cignas website and found a doctor in their network. So I called to set up an appointment.
After I called to set the appointment up, the secretary called to get me approved for the appointment. Cigna then told her that I had to go through the EAP. So I called them to get a referral. They sat me up an appointment to come in for them to get me one. So the day before my appointment, I got a call that they did not do that. They told me that I would have to go through one of Cignas providers, and get a referral from my PCP. I called them and she said she would do it all I needed to do was get the doctors ID number. So I did this and called her back with it she said she would call me back if she had problems or got the referral faxed to the doctor. She called me back and was told by Cigna that they could not give a referral because of the company having the EAP. So I called Cigna and told them my problem. I was told to go to the appointment and have them send the papers to Cigna that someone would have to pay for this, but because of so much conflict, I had to go ahead and pay for this myself.
Wow what a day. My hubby teased me and told me by the time I get to the appt they would probably commit me..lol
I am Honored to be Laurey's Angel. I just pray i do a good job for her .
All of my paper work needed the BTC has got now I'm just waiting for them to send to the ins. to see if they will approve or not.
I called my INS today to find out if they received my paperwork I was told that it was in review with a medical profession and they had requested more they couldnt tell me what it was. So I called the BTC and asked what else they were asking for I was told that my paperwork for what they had wanted hadnt been sent yet. I was told back on Thursday by them that it would be sent out on Monday. I dont know if its me or what but I feel I have to battle at all fronts. She confirmed that my last thing I needed was received on the 9th. She said they are backlogged and it should be sent out sometime this week. I will call back on Thursday to see if it has been yet. I feel like Im harassing these people but when they tell you something then it should be that way. After I calmed myself down (yes Im a very emotional person). I find out that I owe the psychologist another 48 dollars. I already paid 125. I have papers stating office visits are 125. I called to find out I was told they were doing me a favor of charging that but because my ins did pay some it would be 140. They also charged 140 for the test and the paperwork she did. So what they charged the INS was 280 I already paid 125. So I did inform the INS company of what they said, they said they will check into it. I was advised that I should contact the psych board of my exp. with her.
Jan 25, 2003
I was in the hospital for a cyst on my right breast, and I have to go back in two weeks for a mamm. I received my denial letter on Jan. 22,2003 so now I'm back to square one. I have to appeal because of the unprofessional psychologist that I seen. They also said that I didn't have proof of medically supervised diet in the last year, which I do believe that is on my medical charts for my back, that should have been sent, but were not.
Jan 31, 2003
I am sending my appeal out certified mail today. I decided to try to appeal on my own without appeal letters from doctors beings there are 3 and they all want 150 dollars to do this. That way if they still dont approve me I will have time to save money for this. I hope this will help. I did include that I'm not giving up and I do know about the house bill#4 here in Ohio.They also included that they want 2/ 26 weeks of supervised diets with one being in the last 12 months. I do have one which was for 16 weeks. But I included that in studies that dieting is an unineffective way to lose weight permanently. I have dieted and lost weight but it always comes back and usually more.I will update when I hear something.
Ok its been awhile since I updated. I recieved a letter from ins stating that my 2 day staff in the hospital was approved and that if I need anymore follow ups with specailist that my pcp add to refer her. So I went back to my pcp to get this and he said that was unusual that they usually let you have a follow up with no referral. I discussed the denial with him to great links he said he would gladly do an appeal letter if need be. But over the last 2 weeks my sugar has been going high instead of low it has been running between 179 and 205. The psyh. that Im seeing now wants me to have a sleep study done because of my problems with sleep he seems to think I may have sleep apnea. So my pcp had alot to do while I was there. He read over my appeal letter and said it looked good and that he didnt realize how much I had researched this surgery and had all the statics on all the diets and cost that an obese person has. Then yesterday I recieved another letter from my ins. that said they would have my appeal done in 14 days from when they recieved it which was Feb 4 so I should know something by the 18th Im praying alot here that I dont have to get all the appeal letters or hire a lawyer to do another. But now even if they approve me I still have all these other test to complete. Oh well Ive been at it this long Im not gonna give up.
I wanted to share a story with you all. This morning my youngest daughter was getting ready to go to school. As she was opening the door I saw a little sparrow in between the screen door and the hard door and before I could tell her to shut it so hopefully it would push the screen door open it flew in the house. It first flew down the hall to my bedroom and when my husband went in there it flew back out to the living room and perched on the coat rack right by the door he tried to get the door open so it could fly out. But it got scared and flew into the kitchen it was on the microwave close to the window. The kitchen window is about 6ft wide and 3ft long. The sparrow flew up under the blinds and was trapped between the window and the blinds. As it flew trying to get out the window, because it seen the bright blue sky and sun it tried desperately to get through it. My husband finally got his hand under the blinds and caught it he let us look at it and it was a baby then he took in outside and let it fly. I knew exactly how that sparrow felt I could see what I want but just cant seem to get it. Then when he let loose and it flew away I knew thats what I want my freedom from all the pain and misery my body has. God willing I will be that sparrow.
Hi got my appeal back and the approved me I want to first thank God, my family for standing behind me and putting up with my ranting and raving about it. I also want to thank this site I dont think I would of got this far without it. I am going to put my appeal letter I wrote and the stuff I found to send with it and hope it helps anyone else having trouble with their insurance.
January 30, 2003
To whom it may concern,
Im writing to appeal the decision to deny Gastric Bypass Surgery.
I have had a BMI of over 40 for the last 15 years. I do have co-morbidities.
These is a list that I believe fit in the standards.
1) Back injury
2) Arthritis in my knees
4) Heart murmur
I have tried a lot of different diets over the years and none have been a success.
I will not take any stimulants that are for diets beings I have a heart murmur.
I have tried Weight Watchers, bought books to help learn how to count calories.
Dr. Kevin Lake also had me on xenical. This should have been in my records.
I do have depression that Im seeing a counselor Judith Schwartz Ph.D., LISW and a Psychiatrist Kenneth J. Miller M.D., F.A.P.A. They both think that having these will help me. They are willing to write an appeal for me, but I want to try on my own first.
I am going to give you all the reason I believe this is the right choice for me. I did not wake up one morning and decide to have the procedure done. After many failed attempts to lose weight over fifteen years. I see this as a last resort to have a healthy and quality life. I have done a lot of research on this. I know that it is a tool but it is a permanent one where all the other are not. As for my health both my parents have diabetes, heart dieses and hypertension. I know that the loss in weight would help with the pain in my back and knees. I know that I would not be as depressed if I was able to get around more than I can now. I was just in the hospital for 2 days an infection in my breast. I associate this with my obesity because I never got these until after I gained weight. They are a reoccurring infection. It is due to sweat and bacteria that gets under my breast. I fell like Im having to plea here to have a healthy life. I am not going to give up and just get all the health problems that my parents have and live with everyday taking all the medications that are needed to keep them going.
I would like a reply to this and if you do not see fit to approve me this time what steps I have to take. I do not know how many times I have to appeal before I can go with Ohios House Bill #4. I would not have tried to have this procedure done if the doctor and I thought that it was not medically necessary.
I am adding different things that I have learned about obesity and dieting.
Should your company therefore require additional dietary attempts, you are in effect requiring the patient to undergo proven ineffective therapy before you allow a proven treatment regimen, surgery." The statement followed a sentence that said "Medical treatment is well known to be ineffective; with almost all persons who lose weight will regain it within five years". Then they give reference to NIH and the NEJM articles/reports discussing morbid obesity.
This is one small part of a 4 page letter that my surgeon wrote to BCBS on my behave. If anybody wants more detailed info on the 4 pages let me know. "Should your company, therefore, require additional dietary attempts, you are in effect requiring the patient to undergo proven ineffective therapy before you allow a proven treatment regimen, surgery. Denial of coverage may cause serious injury, or permanent disability, through lack of access to necessary surgical treatment. Morbid Obesity has been held by the federal appeals courts to be a disability, under the Americans with Disabilities Act. For an employee, discrimination against such disability, with respect to provision of the contracted medical benefits, may violate the insured's civil rights under that legislation, and May subject the employer or carrier to additional risk."
Economic costs of Obesity:
Obesity has been shown to directly increase health care costs. In an article in the March 9, 1998, issue of the Archives of Internal Medicine 17,118 members of the Kaiser Permanente Medical Care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMIs under 30
Americans spend an additional $33 billion dollars annually on weight-reduction products and services, including diet foods, products, and programs. Most of these expenditures, as is evidenced in this case, are not effective. Rather it can expected that she will continue to gain weight and the costs of co-morbid conditions, including the ones she already has and ones she surely will acquire as time goes on, will far outweigh the costs of gastric bypass surgery that we
Are asking you to please approve for this lady.
Here you will find what we think is the most comprehensive site on obesity and overweight on the Internet. Obesity is not a simple condition of eating too much. It is now recognized that obesity is a serious, chronic disease. No human condition not race, religion, gender, ethnicity or disease state compares to obesity in prevalence and prejudice, mortality and morbidity, sickness and stigma.
The scientists tell us that obesity is due to three primary factors (excluding specific diseases that cause obesity). They are (a) genetics (a predisposition to overweight), (b) environmental exposure to an energy-rich food supply and a tendency to reduction in physical activity and (c) personal behavior.
The High Price of Obesity
If you're obese, you're not alone: so are a record number of other Americans. Roughly 51 million adults are obese. When it comes to being overweight, though, there's no safety in numbers. Your weight can make you the target of discrimination in your personal and professional life. (1) And it can seriously jeopardize your health. Obesity can cause:
heart disease (2)
high blood pressure (4)
high cholesterol (4)
certain types of cancer (5)
gallbladder disease (6)
certain types of arthritis (8)
respiratory disease (9)
premature death (10) The direct health care costs of obesity amount to approximately $100 billion. Another $33 billion a year is spent on weight-loss products and programs, most of which comes right out of consumers' pockets. (11)
If you are in Ohio and you have an insurer that has turned you down (and there is no exclusion specifically for gastric bypass surgery), then you have Ohio Rights!!! House Bill 4 passed in May of 1999 and it was made law and enforced starting in May of 2000.
To learn more about your House Bill 4 Rights, please go to this web site:
PHILADELPHIA (AP) - People who are overweight at 40 are likely to die at least three years sooner than those who are slim, meaning that in terms of life expectancy, being fat during middle age is just as bad as smoking, researchers say.
The study was conducted by Dutch researchers and published in Tuesday's issue of the Annals of Internal Medicine .
Nonsmokers who were classified as overweight, but not obese, lost an average of three years off
their lives. Obese people died even sooner. Obese female nonsmokers lost an average 7.1 years, while men lost 5.8 years.
Scientists have long known that overweight people have shorter life expectancies, but few large-scale studies have been able to pinpoint how many years they lose.
"This study is saying that if you are overweight by your mid-30s to mid-40s, even if you lose some weight later on, you still carry a higher risk of dying," said Dr. Serge Jabbour, director of the weight-loss clinic at Thomas Jefferson University Hospital in Philadelphia. "The message is that you have to work early on your weight. If you wait a long time, the damage may have been done."
For smokers, the results were even worse. Obese female smokers died 7.2 years sooner than normal-weight smokers, and 13.3 years sooner than normal-weight nonsmoking women. Obese male smokers lived 6.7 years less than trim smokers, and 13.7 years less than normal-weight nonsmokers.
The results were culled from vital statistics collected from 3,457 volunteers in Framingham, Mass., from 1948 to 1990. The data were analyzed by researchers at Erasmus Medical Center and the University of Gronigen in the Netherlands.
Obesity is defined as having a body-mass index of 30 or above. The index is a measure of weight relative to height. Healthy weight is a BMI of less than 25.
About two-thirds of U.S. adults are overweight or obese, according to the Centers for Disease Control and Prevention (news - web sites). Studies have also shown that people are getting fatter, younger.
"The smoking epidemic in the Western world is waning; however, a new fear should be the increasing prevalence of overweight and obesity in young adults, which heralds another potentially preventable public health disaster," the researchers said.
March 30 2003
I had my Pats on the 28th they found blood in my urine so now I have to have another test done I dont know what would cause this I just pray it dont stop my surgery. I have gained 16 lbs since my consultation I blame the I had to quit smoking.lol But I also think its I gotta taste this one last time because I know I wont get it after surgery.
April 30 2003
Im finally feeling better to where I can sit here and go through all the messages and answer a few. I am doing good the surgery was easier than I really thought of course I was told to think the worse and then it would seem that it wasnt that bad..lol My energy is still pretty low but I'm walking everyday I walk about a 1/2 mile each day. I need to start making it longer now.
Pets - 2 dogs Max sheppard mix/ Sadie pittbull-black lab
Surgeon Info: Surgeon:Victor Stelmack, M.D.,F.A.C.S
I liked him from the first time I met him he is straight forward. He talks so fast you really have to listen close but he will explain anything if you dont understand or repeat it because you didnt catch what he said. He is very competent and has a great bed side manner. I would not hestitate to recommend him to anybody. Insurer Info:
They were a nightmare to deal with. I could never get the same answer to any question. Never talked to the same person. They lost some of my paperwork. Talked to them one day and they said nothing new just it ws in reveiw next day get a letter from BTC that they needed more info, but they couldnt have told me that the day before. Their right hand doesnt know what the left hand is doing because it is very unorganized. But they were prompt in dealing with my appeal must be completely different departments,Or the fact that I told them I wasnt going to give up was willing to take legal actions if need be. If you deal with them keep a paper trail and always know and write down whom you are talking to.