M. !!!
My journey for Bariatric Surgery began about 4 years ago. I had tried every diet (I felt) known to man. I needed to get my health under control. So I started researching Weight Loss Surgery. I read copious amounts of testimonies from people who had the Roux en Y, Lapband, Duodenal Switch . I read studies after studies. I joined WLS (Weight Loss Surgery) support groups. I read NIH guidelines. I decided after one year of researching WLS that the Duodenal Switch was for me. When I decided to start the process, I found out I was pregnant with my first child. My husband and I were estatic and I put off my journey for WLS for the time being.
Fast Forward to 2007, I have a 2 ½ year old boy name Duke and a 14 month old girl name Coco. Both are the joy of my life. Keeping up with two toddlers is extremely busy, but I love every moment of it! (except when they refuse to go to bed!) My son Duke has Down Syndrome and my husband and I have made sure he is getting the therapy he needs which he has been receiving since 3 months old. He has therapy and everyday and more doctors appointments than most kids. He is a happy, smart, sweet 2 year and he can thrown tantrums with the best of them! But I was finding my self getting out of breath, not being able to get up and down off the floor without a huge production as a lot of therapy is on the floor. My knees and joints were hurting.I basically felt like I was failing my children because of my weight. I decided to start my journey of WLS again.
I called Pacificare to find out about my policies requirement for WLS. I found out it was covered but I must do a 6 month supervised weight loss education with HealthyRoads. I started in May of 2007. I found out 1 month before I was to have finished my requirement that Pacificare no longer required HealthyRoads, however I chose to finish my 6 months.
Once I finished, I made an appointment to see my PCP Dr. Robert Bartz. He was aware of my weightloss journey and was more than supportive of my choice. He wholeheartedly gave me a referral to Dr. Gregg Jossart for a Duodenal Switch as he believed this choice of surgery would be the best for me, and give me the optimal weight loss since I am severely morbidly obese.
I was grateful for Dr. Bartz support and thankful he did not judge me. I was excited that I would be getting the help I needed. As I handed over my referral to his medical receptionist, she informed me that Dr. Jossart was out-of-network. She stated my Medical Group, Brown and Toland contracted their Bariatric Surgery with UCSF Bariatric Program. I was surprised to say the least. I asked her if UCSF performed the DS (Duodenal Switch). I was pretty sure they did not, but things do change . She assured me they did, I had my doubts but I believed her. She made out my referral for UCSF and gave me my paperwork to fill out, she also informed me it could be a up to a year to a year and a half for surgery! Well, she was right about 3 weeks later I received a denial from Brown and Toland. I actually was not surprised. I called Pacificare and was on the phone for 2 hours. The person that helped me went above and beyond. She helped me with my appeal. I had her make sure that the DS WAS covered by Pacificare. It was, which I was glad because this was the whole point of my appeal. I did my appeal over the phone. Hindsight is 20/20 because even though she was so helpful, I’m not so sure she conveyed my need and stressed why I wanted the DS and felt this was the only surgery for me. And that I should be able to go out of network since this surgery which Pacificare DOES cover is not provided by my Medical Group’s IN- Network Bariatric Group, UCSF. I also wanted her to stress in my appeal that waiting 1 ½ years to even get surgery was not even feasible, since I needed help now! I probably should have wrote it and sent it in myself but since this was the first time for me doing this I thought I could do it well over the phone.
On Christmas Eve, I came home from work at 1am from a busy night in Labor and Delivery. The mail was sitting on the kitchen counter. I see a thick envelope from Pacificare and dread fills my stomach. I have a feeling this is a denial letter. The letter states that it is upholding Brown and Toland’s decision, and USCF is who they contract with for Bariatric surgery. I felt like they did not understand where I was coming from and did not treat me as an individual with individual needs. This also could have been because I did not write a letter and did the appeal over the phone.
When I arrived home I looked up UCSF Bariatric Program, online. As I had suspected they did NOT do the DS. Further reading the website I found out it could be just 6 to eight months after evaluation that you may be considered for surgery. I called my Pacificare to see what I should do next. I talked to a lovely lady who helped me figure this out. She said if I really wanted to see Dr. Jossart I should have them send in a referral for him and see if they would let me go out-of network. She stated you never know. So I called my Doctor’s office to ask the medical receptionist to change my referral to Dr. Jossart as Dr. Bartz had originally given me. She was more than happy to but informed me Brown and Toland will probably deny it.
