Recent Posts
Topic: RE: Tricare ins
I'm tricare prime and am wanting VSG. I've been working on this for about a month and have not heard that I can't get VSG by my surgeon's staff. Oh don't tell me I can't get the VSG!! I'm even sleeping with the bleeping sleep apenea mask to get through the process!
WE ARE ALL IN THIS TOGETHER! LET'S GET HEALTHY! 
STARTING WEIGHT 211.8, SURGERY 23 MAR 11; ONEDERLAND 30 MAR 11 199.2 
Topic: RE: can anyone approved by Aetna answer a couple questions for me?1
Hi! I'd be glad to help you with your questions. I was approved by Aetna and had surgery in March 2009. My daughter, approved by Aetna and had surgery in May 2010 and my two sons both just had surgery in Dec 2010, both being approved by Aetna. Three of us did the # month multidisciplinary program and my one son did the 6 month physician supervised diet. So I pretty much have it nailed down as to what they are looking for with the 3 month MD program. I will send you a PM that details what we did for our approval.
To answer your question about the exercise consult. It has to be documented in the notes to the PCP. I work at a place where we have health facilities right here. I went to the health center and had an excercise specialist set me up on a weight training/cardio program. I took a copy of that along with a letter signed from that person stating that I had been set up on an exercise program. That is all that I did for the exercise part of the requirements other than my PCP documenting in her notes that I was continuing my exercise program set up by so and so.........
One thing to keep in mind is this is a 90 day program - not 3 months. So Aetna will count out 90 days from the time you saw your physician and dieticien and go from there.
As far sa the success vs failure on the supervised diet.....during my 3 month MD program, I gained 6 pounds. My daughter dropped about 5 lbs and my sons each dropped about 10. I don't think it matters either way! (as long as you don't drop enough to push your BMI under 40!!)
I'll PM you. And feel free to ask any questions you may have. Two of us were denied at first and I appealed and the decision was overturned, so I have experience filing appeals with Aetna too. You have to make sure all your i's are dotted and t's crossed and it can be a very easy approval. But if you don't, they will definitely deny.
Sounds like you are well on your way to a good start. Key thing to remember is your PCP is the one who has to keep everything in his/her notes!
And they will be looking for the 'behavior modification' requirement. I talked to my dietician and my physician about behavior modifications I was making (joining a support group, not drinking with meals, cutting out pop, etc....) and both of them documented it in their notes.
Hope this helps!
Nan
To answer your question about the exercise consult. It has to be documented in the notes to the PCP. I work at a place where we have health facilities right here. I went to the health center and had an excercise specialist set me up on a weight training/cardio program. I took a copy of that along with a letter signed from that person stating that I had been set up on an exercise program. That is all that I did for the exercise part of the requirements other than my PCP documenting in her notes that I was continuing my exercise program set up by so and so.........
One thing to keep in mind is this is a 90 day program - not 3 months. So Aetna will count out 90 days from the time you saw your physician and dieticien and go from there.
As far sa the success vs failure on the supervised diet.....during my 3 month MD program, I gained 6 pounds. My daughter dropped about 5 lbs and my sons each dropped about 10. I don't think it matters either way! (as long as you don't drop enough to push your BMI under 40!!)
I'll PM you. And feel free to ask any questions you may have. Two of us were denied at first and I appealed and the decision was overturned, so I have experience filing appeals with Aetna too. You have to make sure all your i's are dotted and t's crossed and it can be a very easy approval. But if you don't, they will definitely deny.
Sounds like you are well on your way to a good start. Key thing to remember is your PCP is the one who has to keep everything in his/her notes!
And they will be looking for the 'behavior modification' requirement. I talked to my dietician and my physician about behavior modifications I was making (joining a support group, not drinking with meals, cutting out pop, etc....) and both of them documented it in their notes.
Hope this helps!
Nan
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
Topic: RE: Help with insurance lingo
Much to say here regarding MX and bypass. ;o)
Bypass, it's a trade off. You'll lose the same with bypass as you will with a sleeve, statistically speaking. The trade off is faster weight loss with bypass in exchange for a lifetime of malabsorbing nutrition. You'll only malabsorb calories for 6-24 months but you'll malabsorb nutrition forever. With bypass you have high risks for vitamin deficiencies, reactive hypoglycemia, and dumping, you also risk bowel obstructions for life. About 3 years post op bypass you are seriously metabolically challenged so losing a pound 3 years post op is not like losing a pound today. And in the end you have to follow a sleeve diet to maintain anyway. So is the trade off worth it?
Bands are horrible surgery types, sleeves are the safest surgery type long term, bypass is great for people with severe reflux not caused by obesity or a hiatal hernia, and DS provides the best weight loss long term.
Sleeves... it removes Ghrelin produced by the stomach and Ghrelin is what tells your brain you are hungry. Most sleeved people don't experience hunger often. About the only time I do is if I eat a lot of white carbs. Then the blood sugar spikes cause hunger. But otherwise, I might experience stomach hunger a few times a year. Bypass requires lots of labs, sleeves require far fewer labs since we don't malabsorb.
Bypass folks often times dilate their stoma. Food acts like a water slide down their esophagus, through their pouch, and into their small intestine, they are always hungry and since they aren't malabsorbing anymore the regain starts. Since they are metabolically challenged they have a hard time losing that regain.
Sleeves... perfect restriction forever, your pyloric valve isn't stapled off so you have a fully functioning smaller stomach minus the Ghrelin.
Mexico... much to say about that. There are really great doctors and bariatric butchers in every country including MX and the US. See this:
http://wasabubblebutt.blogspot.com/
Those are examples of US and MX surgeons that are questionable.
This is why research is critical regardless of who does your surgery in any country and you do it this way:
http://wasabubblebutt.blogspot.com/2010/03/researching-mexican-or-us-sleeve.html
I went to a fantastic surgeon and a fantastic hospital. I had my band there and then I revised to a sleeve there. I'm having my plastics done at the same hospital as well.
You just want to avoid Tijuana and Juarez, they are too dangerous and really, IMHO there are no good bariatric surgeons in Tijuana or Juarez anyway. When the US, MX, and Canadian gov'ts warn about Mexico it is not the entire country they are warning about, it's very specific cities.
You know, most of the popular MX surgeons have more experience than most US surgeons. They have been doing bands for 10 years longer than US surgeons, they were saying years ago sleeves are the way to go. US surgeons were drinking Allergan's kool aid and they were just sure bands were the way to go. Turns out the MX surgeons were right but they've been doing stand alone sleeves longer than US surgeons so of course they had experience with both.
I can't speak for all the doctors in MX but my surgeon... there are no hotel fees. He keeps you in the hospital until you are okay to go home. Two nights for bands, three nights for sleeves, and a week or so (I forget if it is 6-7 nights) for bypass. I don't know how long he keeps you for DS. You arrive the day before your surgery for pre ops and then you do go to a hotel the night before surgery. That's included in the package price and the doctor's driver provides ALL transportation from when you arrive in San Diego, from hospital to hotel, from hotel to hospital, and from hospital to the San Diego airport. So, no transportation costs once you arrive in San Diego.
I paid more because back in the day it cost more! ;o) Today it is $8750 and figure in a $250 airfare ticket. You are talking $9K for surgery in a US inspected, Joint Commission Hospital.
http://www.jointcommission.org/
My surgeon has done well over 1000 sleeves, thousands of bands, around 500 bypass and I don't know how many DS. His stats are great. My sis is considering a sleeve and I won't let her go anywhere but my surgeon.
There is much to research regardless if you stay locally or travel. My surgeon is my personal pick, that's why I went to him! ;o) But he's not the only good surgeon in MX, there are about three that I would personally go to.
So how was my experience? I had perfect surgery twice and I plan on having two more perfect surgeries for plastics. At the time I lived in Phoenix and so my surgeon was driving distance for me for aftercare with a band but there is no aftercare for sleeves.
My surgeon is a proctor surgeon, meaning he travels the world one week out of every month teaching other doctors sleeves and bypass. He was previously a proctor surgeon for US docs when the band was approved in 2001.
BTW, regardless if you have surgery in the US or MX don't forget, all your expenses are tax breaks if your income qualifies. ;o)))
Bypass, it's a trade off. You'll lose the same with bypass as you will with a sleeve, statistically speaking. The trade off is faster weight loss with bypass in exchange for a lifetime of malabsorbing nutrition. You'll only malabsorb calories for 6-24 months but you'll malabsorb nutrition forever. With bypass you have high risks for vitamin deficiencies, reactive hypoglycemia, and dumping, you also risk bowel obstructions for life. About 3 years post op bypass you are seriously metabolically challenged so losing a pound 3 years post op is not like losing a pound today. And in the end you have to follow a sleeve diet to maintain anyway. So is the trade off worth it?
Bands are horrible surgery types, sleeves are the safest surgery type long term, bypass is great for people with severe reflux not caused by obesity or a hiatal hernia, and DS provides the best weight loss long term.
Sleeves... it removes Ghrelin produced by the stomach and Ghrelin is what tells your brain you are hungry. Most sleeved people don't experience hunger often. About the only time I do is if I eat a lot of white carbs. Then the blood sugar spikes cause hunger. But otherwise, I might experience stomach hunger a few times a year. Bypass requires lots of labs, sleeves require far fewer labs since we don't malabsorb.
Bypass folks often times dilate their stoma. Food acts like a water slide down their esophagus, through their pouch, and into their small intestine, they are always hungry and since they aren't malabsorbing anymore the regain starts. Since they are metabolically challenged they have a hard time losing that regain.
Sleeves... perfect restriction forever, your pyloric valve isn't stapled off so you have a fully functioning smaller stomach minus the Ghrelin.
Mexico... much to say about that. There are really great doctors and bariatric butchers in every country including MX and the US. See this:
http://wasabubblebutt.blogspot.com/
Those are examples of US and MX surgeons that are questionable.
This is why research is critical regardless of who does your surgery in any country and you do it this way:
http://wasabubblebutt.blogspot.com/2010/03/researching-mexican-or-us-sleeve.html
I went to a fantastic surgeon and a fantastic hospital. I had my band there and then I revised to a sleeve there. I'm having my plastics done at the same hospital as well.
You just want to avoid Tijuana and Juarez, they are too dangerous and really, IMHO there are no good bariatric surgeons in Tijuana or Juarez anyway. When the US, MX, and Canadian gov'ts warn about Mexico it is not the entire country they are warning about, it's very specific cities.
You know, most of the popular MX surgeons have more experience than most US surgeons. They have been doing bands for 10 years longer than US surgeons, they were saying years ago sleeves are the way to go. US surgeons were drinking Allergan's kool aid and they were just sure bands were the way to go. Turns out the MX surgeons were right but they've been doing stand alone sleeves longer than US surgeons so of course they had experience with both.
I can't speak for all the doctors in MX but my surgeon... there are no hotel fees. He keeps you in the hospital until you are okay to go home. Two nights for bands, three nights for sleeves, and a week or so (I forget if it is 6-7 nights) for bypass. I don't know how long he keeps you for DS. You arrive the day before your surgery for pre ops and then you do go to a hotel the night before surgery. That's included in the package price and the doctor's driver provides ALL transportation from when you arrive in San Diego, from hospital to hotel, from hotel to hospital, and from hospital to the San Diego airport. So, no transportation costs once you arrive in San Diego.
I paid more because back in the day it cost more! ;o) Today it is $8750 and figure in a $250 airfare ticket. You are talking $9K for surgery in a US inspected, Joint Commission Hospital.
http://www.jointcommission.org/
My surgeon has done well over 1000 sleeves, thousands of bands, around 500 bypass and I don't know how many DS. His stats are great. My sis is considering a sleeve and I won't let her go anywhere but my surgeon.
There is much to research regardless if you stay locally or travel. My surgeon is my personal pick, that's why I went to him! ;o) But he's not the only good surgeon in MX, there are about three that I would personally go to.
So how was my experience? I had perfect surgery twice and I plan on having two more perfect surgeries for plastics. At the time I lived in Phoenix and so my surgeon was driving distance for me for aftercare with a band but there is no aftercare for sleeves.
My surgeon is a proctor surgeon, meaning he travels the world one week out of every month teaching other doctors sleeves and bypass. He was previously a proctor surgeon for US docs when the band was approved in 2001.
BTW, regardless if you have surgery in the US or MX don't forget, all your expenses are tax breaks if your income qualifies. ;o)))
Previously Midwesterngirl
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
Topic: BCBS Healthselect State of Texas employees
I have search for this and didn't come up with anything. I don't post a lot....just a long time lurker. But I have a question:
Has anyone had any luck getting approved with BCBS Healthselect for State of Texas employees (ERS)? I am almost finished with my 12 month attempted weight loss requirement and I am just wondering.
Has anyone had any luck getting approved with BCBS Healthselect for State of Texas employees (ERS)? I am almost finished with my 12 month attempted weight loss requirement and I am just wondering.
Topic: RE: Help with insurance lingo
Thanks for your response. I'm not really set on having gastric bypass, but I'm a little nervous about going out of the country. How was your experience in Mexico? I didn't know if it would be worth it, with paying for airfare, hotel fees, etc. About how much did you end up paying including all expenses?
Topic: any one live in Connecticut???
Hi everyone. I am wondering if any one in ct has community health network (husky) insurance??? Has anyone been approved denied for surgery? I really want to have the vbg done but i dont think they will cover that specific procedure... anyone else have any problems?
Topic: RE: Update: Approved! (Anthem is giving me hissy fits)
Congratluations on your approval =) Sounds like you had a fairly easy time--as it should be!
And hey, I'm originally from Westfield! (You probably just refer to it as "North Carmel" ;) )
Best wishes,
Jonathan
And hey, I'm originally from Westfield! (You probably just refer to it as "North Carmel" ;) )
Best wishes,
Jonathan
Topic: RE: 12 month program
BC/BS wouldn't use the notes from my PCP, but they weren't good notes (they weren't intended to be, so I don't blame my PCP) and I had to start my program over w/ my surgeon; however, it was only a 3 month program.
I hate that some insurance companies have gone to a 12 month weight management program. Do they really think we've never tried to lose weight before? Or even better, do they really think we've never LOST weight before, just to gain it back, like 95% of everyone else?
I will tell you this, even if you don't believe me. The time will pass, and it will pass quickly. Don't give up. That's what they want you to do. That's the ONLY reason I can see them requiring an entire year of weight loss program before approving.
Good luck, and God bless.
I hate that some insurance companies have gone to a 12 month weight management program. Do they really think we've never tried to lose weight before? Or even better, do they really think we've never LOST weight before, just to gain it back, like 95% of everyone else?
I will tell you this, even if you don't believe me. The time will pass, and it will pass quickly. Don't give up. That's what they want you to do. That's the ONLY reason I can see them requiring an entire year of weight loss program before approving.
Good luck, and God bless.
Topic: RE: Psych Eval?
My psych eval result wasn't exactly a glowing recommendation. They asked me to fill out over 25 pages of paperwork before they saw me, in which they asked for the same information over and over again. I quit filling out forms that were clearly repetitive, and when he wrote my evaluation, he said something to the effec that I "don't follow directions well," and that may have an impact on my success with weight loss surgery. He wrote that if the doctor's office put a high priority on motivating me, I might do ok.
Pretty arrogant, I thought, considering he based that on me not wanting to write my social security, address, and health insurance information in 20 different places.
Anyway, I did have a point here.. =) BC/BS IL approved my surgery, and never mentioned the psych eval.
But, if you're asked to fill out 25 pages of paperwork.. do it. =)
Peace,
Jonathan
Pretty arrogant, I thought, considering he based that on me not wanting to write my social security, address, and health insurance information in 20 different places.
Anyway, I did have a point here.. =) BC/BS IL approved my surgery, and never mentioned the psych eval.
But, if you're asked to fill out 25 pages of paperwork.. do it. =)
Peace,
Jonathan
Topic: RE: Approved!
On December 15, 2010 at 2:15 PM Pacific Time, Saintsfan1 wrote:
"... just got my denial once again ..."
Amazing. That's my same story. BCBS/IL. Deny, deny, deny. We asked them EXACTLY what they needed to see, and it was information the doctor had ALREADY sent them. I said, "Look at page 17." They said, "We''ve denied the claim, and we're not looking at it anymore." I tried to explain that they denied it saying there wasn't documentation that clearly existed. It was like talking to a brick wall.
I found an advocate within the system (through my employer ) who wouldn't give up, and they FINALLY approved it.
I wish you the best of luck w/ your battle w/ BC/BS IL. They've been great about ever medical need I've ever had, except for this surgery. But, in the end, they finally came through. I'll be having surgery in 6 days.
Sorry for your struggle. Keep the faith.
Jonathan
"... just got my denial once again ..."
Amazing. That's my same story. BCBS/IL. Deny, deny, deny. We asked them EXACTLY what they needed to see, and it was information the doctor had ALREADY sent them. I said, "Look at page 17." They said, "We''ve denied the claim, and we're not looking at it anymore." I tried to explain that they denied it saying there wasn't documentation that clearly existed. It was like talking to a brick wall.
I found an advocate within the system (through my employer ) who wouldn't give up, and they FINALLY approved it.
I wish you the best of luck w/ your battle w/ BC/BS IL. They've been great about ever medical need I've ever had, except for this surgery. But, in the end, they finally came through. I'll be having surgery in 6 days.
Sorry for your struggle. Keep the faith.
Jonathan
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