BCBS MI questions

Hello,

I just found out today that my doctor wrote a "recommendation for bariatric surgery" letter for me today. 

I have to admit it was out of the blue and while its welcome, i still feel that i will get denied.

Allow me to explain.

Later last year i was finally diagnosed with severe sleep apnea after having it for most likely 5+ years.  I have an average of 2 apneas per minute, with the longest one during my sleep study lasting 60 seconds[couldnt do that under water if i tried].  I am now on a cpap and have been for 5 months but unfortunately it has done NOTHING except mess up my excellent hair-do. 

16 months ago i had a knee operation [simple scope] and had my torn meniscus repaired.  While the wounds healed the damage was far from over.  Unfortunately i learned the hard way that my knee will never heal until i lose weight.  This really sucks since eventhough im like a walking zombie-like beached-whale, i still enjoy a good game of paintball every now and then and this was the final nail in the coffin for that.

My gall bladder went kaput last year.  had the heida scan [sp?] done and a normal ejection rate is around 80% or something, and mine was .005%.   So thats toast and i have yet to have it removed [doesnt hurt and im a busy guy]

I'm hypoglycemic too.  All i know about this is i get hungry all of a sudden, coupled with shaking hands, migraines, and abdominal pain until i stuff my face full of Denny's food.  Then i don't get full like normal people either, i usually overeat because i dont feel full until it hits me that im stuffed all of a sudden and i stop.  its really weird and annoying and having never been someone else [that would be neat] i had no idea it wasnt the norm.

My Blood Pressure was something like 180/130ish and now with the joy of Benicar its around normal levels again.  My cholesterol is extremely high as well, etc.

I have alot of medical problems relating to this weight problem as most of you here do/did i'm sure.  What i DON'T have is 12 months of consecutive medically-assisted weight loss attempts.

I'm not a liar like some, and I can admit flat-out that i am consciously unable to keep on a diet without some assistance.  My work schedule coupled with a few other B.S. excuses i can throw at you prevent me from sticking to any diets.  <-- sarcasm.. weeeee

Simply cannot stick to them at all for one reason or another.  In my corner.. i do work 50-80 hours a week, but for the most part its my fault.  I want to diet and exercise but my knee problems coupled with having NO energy from the apnea [and i do mean NO energy at all] make exercise impossible.  I tried the energy bar diet for a month.. jeeze those taste horrible and i was still starving afterwards, not to mention they had phenalylalinelinineine or however u spell that stuff, in it.

My doc wrote this letter because he knows im dead in a few years unless i get something drastic done.  I hate the surgery and i wish there was a better option but im a realist.  Being dead at my age would suck.. not seeing my neices grow up, and i wouldn't be able to look forward to all those years with no social security checks rolling in either.... =[

I am 360lbs last i stepped on the cattle-scale and i am 6'1" which gives me a really high BMI [my mommy always told me to aim high] and i am just now 25 years old.

My LAST problem i would like some help with is that when i go to my doctors frequently for various problems, apnea, knee, migraines, etc, i do not fit on their scale anymore.  That was a REALLY bad day when i found that out.  i used to fit but once i went over 350 it just said "GET OFF FATTY!". 

My question is this: No 12 months consecutive dieting, no actual weigh-in at the doctors anymore, and all i have is a doctors note like in high school.  I was actually, up until last year, poor and insurance-less, so proving 5 years of whatever they need is out of the question because for one of those years i lived in my car...  oh yeah back to the question, are my chances bleek or should i give it a shot?  Michigan seems to suck well water through a paper straw when it comes to this stuff so I'm not very optimistic.  Come to think of it, its been years since i HAVE been.

I'd love to hear that my doctor's note can whoosh me away to surgery land but its not lookin like that matters much.

Any help is appreciated, sorry for writing a book. EDIT: seems this site does not like opera browser.. had no spaces, etc.

Hi, I am really sorry to hear your story.  I too have BCBS of MI.  I am going through the physician supervised diet now because they previously denied me. From what I have learned since researching this surgery, the insurance companies aren't looking at this prerequisite as a way to get out of paying for your surgery.  What they want, before they approve us, is for us to achieve a "healthy" weight so there will be less complications during/after surgery.  This is better for us health wise, and better for them, money wise. I can relate on the bad knee, but there are other forms of exercise you can do.  You may not have any energy to exercise, but a 10-15 minute walk twice a day doesn't take much energy, but will certainly burn calories. You're only 25 years old, you have your whole life ahead of you.  Trust me, it can be done.  I used to weigh over 400 lbs and got down to 280 by walking and cutting carbs.  Unfortunately for me, I had to have back surgery and wasn't able to walk for awhile.  That coupled with eating carbs again, I have gained 50 of it back, but I'm back at it.  I did it before, I can do it again, and so can you.  When you're feeling down and want to put that potato chip in your mouth, just tell yourself, you don't need it!  You may want it, but you do not need it.  Get tough on yourself!   Even if you lose 20 lbs while on this supervised diet, that'll be 20 lbs closer to a healthy weight and healthy lifestyle.  Remember, the surgery isn't a miracle cure for obesity, it is an aide, that will require discipline and hardwork as well.  You may as well get started now.  Nothing tastes as good as being thin feels!!!! ~Traci

hmm.. Thanks for the reply but you didn't answer my question at all really =[ IF i achieved a healthy weight i would have no reason for the surgery... I do not eat potato chips, candy, junk, etc.  And i certainly do not eat out of depression or some mental reason like dependency.  I eat until my body tells me im full, which is sometimes too late.  i dont often "over eat" in that i eat the same portions as everyone else around me, aside from very specific instances.  Your potato chip comment doesnt apply to me at all unfortunately.  i persoanlly cant stand potato chips. I'd suggest you research severe sleep apnea a bit more, because a simple walk a day would do absolutely nothing to help my knee, and im also a believer that if you dont break a sweat you arent doing anything to lose weight either.  I was in a very intensive physical therapy program three times last year and due to sleep apnea never letting your body enter regeneritive sleep your muscles simply do not tear and heal the same as everyone else.  Mental and muscle regeneration is a stage of sleep that i literally never hit and haven't for probably 5 years.  when you sleep your body enters a deep subconscious sleep where you dont twitch, you dont toss and turn, and your body has a chance to relax and heal itself.  Mine doesn't.  My doctor is aware of this, hence the need for surgery. Trust me... 3 physical therapy appointments a week for a total of 6 months last year and i didnt gain or lose a pound?  My knee specialist thought it was very odd as well until i got tested for apnea then it all made sense.  all i was doing was putting myself through hell for absolutely nothing. Back on topic, he did write in the letter that i have tried dieting over the past year off and on with minimal success.  is that all bluecross needs to see or do they need more specifics? And I'm glad to hear that you have the will power and determination, not to mention physical ability to get down on your own, but i do not.  For me, surgery is the only option.  My only hopes for surgery is that i get it, lose the weight, get the energy back, drop the apnea and can exercise and build up a ton of muscle.  i never want to feel this dead again.

Excuse me if I offended you, I was merely trying to encourage you and anyone that read this post. To answer your exact question, seeing as I don't work for BCBS and I can only answer from my own personal experience, I don't believe they will simply take a note.  I had a note too.  They require thorough documentation from you doctor proving that you've followed a supervised diet and lost weight. I'd suggest you research these boards to see how many people have tried and been denied without proper documentation. Good luck

i did. seeing as how BCBS seems to handle things very differently from state to state, on top of the fact that they seem to change their policies often i figured the best way to the answer was to make my post and get updated info. Thanks for the answer.  I can get all of the charts from the doctor if needed so that may help. Not offended, i just get tired of explaining apnea to people and then still having them not understand or believe it.  I absolutely hate hearing "just exercise and eat better" since its such a generalized response i see far too often.  I doubt anyone on here is that dumb that they don't realize exercising and dieting may help them lose weight, yet everyone still feels the need to tell us. Like i said it just doesn't help me much.  I cant document any weight loss with the doctor because i havent lost any through all of the tries. Like i said thanks for the answer, i'll check into it more with my doctor.

I am in a similar situation in that I've had physical therapy for my back and I've also been on a gestational diabetes diet for a few months.  I am seeing my doc now as a back up plan in case I get denied. I have BCBS of IL.   I would say to you what my surgeons insurance lady said to me.  It is really a crapshoot with BCBS.  If your file lands on the desk of someone that feels empathy for your situation, then they might count the physical therapy and the doctors note as the 6 months.  If you get someone that has no sympathy, they will probably require every single bit of every single piece of information to issue you an approval.  I would print out a copy of what your insurance requires, give it to your doc and take the steps from there.   That way if you do get denied, at least you are doing something while you put together your appeal.  Just my advise, hope it helps.

hey, thanks for the reply. I asked my employer and our HR person is not the best in the world.  She has no idea how to get that information.  Do you know where on BCBS's website i might find this document?

I tried to locate it on their website and couldn't. The site that I use is bcbsil.com.  The site for you would be bcbsm.com.  I would call the phone # on the back of your insurance card and have the customer service rep guide you through the website to where it's at.  That's the only way I found out where my policy info was the first time.  Hopefully that should give you the info you need.  I printed out the criteria for my doc to follow and if I get turned down this time, I know I will have the documentation down to a T the next time.  Good luck!

I, too, have BCBS of Illinois. The lady I spoke with at the insurance company told me to go to bcbsil.com/medpolicy and type in morbid. The policy that they have on surgery for the morbidly obese should pop up and you click on that. It should contain a full description of what they require.  Hope this helps!!! Karen

This is all i could find: http://www.mibcn.com/home/where_you_can_go_for_care/coe_bariatric.shtml ........... they sure do make it seem like they don't want to help...