judylj60
247 lbs 5'4" .... Dr's office says I'm on a waiting list and it will be a year before my first consult
September, 2002 - I've gotten a letter giving me my first appointment date. Not until December 4th though! :-( According to the information sent to me, after my appointment in December it may be another 4-6 months before my surgery. My weight is now up to 252.
October 8, 2002 - I have been suffering with back pain. Yesterday I went to an ortho. doctor. He has diagnosed degenerative disk disease at L4-L5. I guess this will be one more reason why I need this surgery. Called my surgeons office today and they confirmed that DDD is a comorbidity.
December 4, 2002 - I had my first consultation visit with the surgeon's office today. My weight is now up to 260. I quit smoking on September 13th and I guess that is one reason for my gain. I didn't get to meet the surgeon because he was called out of town. I was told I should be a good candidate for lap RNY. I should be getting pre-op test appointment times in the mail in a couple of weeks. From what I'm told I should only need to have an upper GI and gallbladder sonogram. The surgeon's office said that I might be looking at a March surgery date. I can hardly wait.
I'm scheduled for my pre-op testing on January 14th. I am supposed to have an abdominal sonogram, upper GI and lab work. I cannot wait....it finally feels like I'm getting somewhere in the process.
January 14, 2003 - I went for my pre-op evaluation testing today. I had an abdominal ultrasound, upper GI and blood work. As soon as they can get the results back to the doctor then I will have a decision visit with my doctor and then his office will seek insurance approval.
February 5, 2003 - I'm still waiting for my decision visit. It's been three weeks since my tests. I called the doctor's office and I was told that I would be called when they received everything back from my tests. They said if I hadn't been called then they must not have everything back yet. I find this hard to believe since I only had blood work, upper GI and abdominal ultrasound. They wouldn't even check to let me know what was the holdup.
February 10, 2003 - Called the doctor's office again. All my test results have come in but the doctor's have their calendars with them in clinic so she couldn't give me an appointment for my decision visit yet.
February 13, 2003 - Called the doctor's office again. I finally have a date for my decision visit....unfortunately its not until March 18th. I wish I had more patience...that's just not my nature. I've already been waiting a year (it was about a year ago that I was put on the doctor's waiting list) and I'm still about 4-5 months from surgery....it is soooo frustrating. I know my surgeon is fantastic and has a great reputation so the wait is probably worth it but I am sooo ready for this to happen.
March 12, 2003 - Doctor's office called and left a message that they need to reschedule my decision visit. I have now been scheduled for April 8th. I wish I was good at waiting. This will add three weeks to my wait. I know the wait will be worth it but after already waiting a year I'm getting anxious. Then again what is another 3 weeks when I've already waited a year. I just want to start my new after-surgery life.
June 23, 2003 - Much has happened since I last posted. I had my decision visit but prior to filing for insurance my doctor's office discovered that my insurance carrier (CIGNA) is now requiring psych eval and nutritional consult. I had my psych eval on May 12th and my nutritional consult on May 15th. The doctor's office faxed 36 pages of supporting documentation, including the surgeon's letter of medical necessity, to CIGNA on June 3rd. CIGNA denied receipt for 10 days the acknowledged receipt on June 3rd by claims. But claims don't handle this any more. Now pre-certification is handled by CIGNA's subsidiary IntraCorp. According to CIGNA it will take 10 days to forward the information in-house. Contacted the doctor's office and requested the package be re-faxed to IntraCorp. Received my denial of benefits today stating "Although the patient has the benefit for bariatric surgery based on medical necessity, ... no documentation of weight loss attempt ... of at least 26 weeks, ... within the past 12 months and documents at least monthly weight-ins." I have been going through this process, including my doctor's waiting list, for over a year now. I have been on three doctor supervised diets in my life time and God only knows how many other diets, ie Weight Watchers, Diet Center, Protein Power, Atkins, etc. How many failed diets do they need...why does it have to be in the last 12 months? I'm so upset. I wish I could afford to hire an attorney.
July 1, 2003 - I received word that I'm going to be laid off July 31st.
July 15, 2003 - I have found a new job and start on July 28th.
July 25, 2003 - Went for new employee orientation.....ugh...they have Cigna too.
August, 2003 - Cigna says under the new policy I have to have a referral from my PCP even though I have already been going to the surgeon. It will be mid-September before I can get in to see my new doctor.
September, 2003 - Saw my new doctor and he has no problem with giving me a referral to Dr. MacDonald for gastric bypass.
October, 2003 - Called Dr. MacDonald's office to give them the new insurance information now that I have the referral from the PCP. I'm told that Cigna has once again changed their criteria.
November 5, 2003 - Dr. Macdonald's office faxed my information to Cigna.
November 14, 2003 - I called Cigna today the lady in claims checked with Health Services. She said they have my paper work. She gave me the authorization number in case I need to call again. She said that it hasn't been approved or denied yet. She says Cigna requested additional information from my doctor on November 11th. She told me that once they get that information I will have an answer within 24-48 hours.
November 18, 2003 - I called Cigna again today and spoke with Brian. He looked in the computer in claims and said there wasn't anything in the system yet. I gave him the authorization number. He put me on hold to check. When he came back on the hone he said that I had a valid authorization number. He asked hen my surgery was scheduled. I told him it wouldn't be cheduled until we heard from Cigna. He said that if I had the uthorization number then it must be ok......I hope he is right ut I have a feeling that Brian doesn't know what he is talking about.
November 20, 2003 - I received a copy of a letter from Cigna to Dr. MacDonald. I guess this is their "outreach". I was told they did an outreach on 11/11, but this is dated 11/17. It says:
We received a request from you on 11/07/2003 for Judith Johnson for the following service/procedure(s):
*Gastric Bypass (43846)
After a review of the information submitted, we are for the requested procedure/service(s). In order to process your request, we will need the following additional information:
*documentation of physician supervised diet for a minimum of 6 mo. to include exercise, diet, behavioral therapy, pharmacotherapy, monthly weights and nutrition eval.
It asks them to send the information promptly to a Carrollton, TX address, attention Kelli Cannon. I was on a seven month diet, and have all the notes the doctor created for me. I noticed that this letter didn't say that I had to have 2 diets nor did it say that the diet had to be within the last year. Anyway, the notes I have show that I was on phentermine (diet drug), low calorie diet, he wrote notes for me on exercise and behavorial modification....the only thing is I started at monthly weigh-ins and then it went to bi-monthly weigh-ins. Dr. MacDonald's office has all of this. I can't imagine that they didn't send it in. They sent me the package they sent when I was under the other employer's insurance and it included those notes. I don't think I will be able to get the doctor's notes from the doctor because he is retired now and I'm not even sure he is still alive.
I guess this is still not a denial....it is their request for further information.
Now what do I do?
December 5, 2003 - Cigna is getting ready to deny me based on medical necessity because of lack of a doctor supervised diet (their newly changed criteria as of October 1, 2003). I just talked with Cigna again. I asked them how I would ever be approved for this procedure if they are constantly changing their criteria for medical necessity. I told the girl that I had been pursuing this procedure since March 2002 when I got on the doctor's waiting list. She put me on hold for 10 min. When she came back she said they would be glad to send me the criteria that is now in effect. I told her that was funny because 1-2 months ago I asked for the procedure and was told it was confidential and they wouldn't send it to me. I asked if they were going to cover my seeing a diet doctor ... she just kept reading me the exclusion language and wouldn't ever just say yes or no. I finally told her to let health services know that if they denied this procedure that I wouldn't do one more thing....not one....to control my weight and they could pay for my triple bypass; control of my diabetes; back surgery; knee replacement surgery and all the other effects of my weight. I told her that I had an uncle and grandfather who both died at the age of 42 from heart attacks. I told her that when I died my early death I would leave notes and instructions for my children to sue Cigna for killing me because in effect that's what they would be doing by not paying for this medically necessary procedure. The girl at Cigna was typing as fast as she could. She told me I should have my doctor call health services to discuss the procedure.
December 8 2003 - Received a letter today, dated December 2nd, that states that on or after January 1, 2004 CIGNA HealthCare will exclude benefit coverage for all forms of bariatric surgery for obesity. These procedures will be specifically excluded for dates of service on or after the effective date of the group renewal (my group renewal is January 1st). For dates of service prior to the group renewal, these procedures will continue to be covered if medically necessary.
And if you really want to laugh .... they state:
If you are still considering this procedure, please have your treating provider submit a prior authorization request to CIGNA Health Care no later than December 15, 2003. This will allow us adequate time to review the request and determine whether it meets our medical necessity criteria. This should also allow adequate time to schedule the procedure before the current 2003 plan year ends. Again, surgery performed on or after your group renewal date will not be a covered benefit.
Yeah. Like Dr. MacDonald would be able to schedule me in between now and the end of the year even if they did approve me.
December 15, 2003 - I received my denial today. They have denied me saying that I do not qualify as medically necessary because of their ever changing diet criteria. I spoke with the Insurance Commissioner's office and they say that it is their legal opinion that since I am already in the process of approval/appeal, Cigna will have to pay for the surgery if their denial is overturned. I will be filing an appeal.
January 15, 2004 - A friend I met through my WLS journey who happens to have insurance under the same employer's plan has just gotten word that Cigna's denial of benefits for her wls has been overturned by the external review. She is so excited. I am excited because we are in the same policyholder group, were denied for the same reason, have the same group of doctors, have fairly close BMIs (both over 45), have comorbid conditions, got on our doctor's waiting list in March 2002 and went for our initial consults a day apart from each other. This has been a long journey for both of us. If her denial was overturned then mine should be too ... for the same reason. Maybe my long wait will be over soon.
February 6, 2004 - I decided to hire somebody to help me with my appeal. The matter was soooo emotional for me. I forwarded her my plan book, my denials and the full package my doctor's office had forwarded to Cigna. She put together an excellent letter. I sent this appeal into Cigna National Appeals today. (If anyone needs help with their appeal -- [email protected] ... she is fantastic .... and I don't usually like to give personal recommendations!!)
February 7, 2004 - Cigna signed for receipt of my appeal package today.
February 18, 2004 - Received a letter from Cigna verifying they received my appeal on "February 11". I have a receipt showing they signed for it on February 7. This insurance company does anything they want to stall and deny. Their letter also stated that the appeal was initiated by my orthopaedic doctor. It wasn't. I sent the appeal in and included, among other things, a letter from my orthopaedic doctor supporting my effort to get this surgery. Does Cigna ever get anything right?
March 15, 2004 - I'M APPROVED!!!!! I can hardly believe it. It has already been such a long journey. The guy from Cigna who called to let me know said he would fax the authorization to my doctor's office tomorrow morning.
March 17, 2004 - I have my surgery date. I go for pre-op on April 20th and I have my surgery on April 23rd.
April 22, 2004 - I can't believe it's finally here!!! Just 9 hrs until surgery. I have to be at the hospital at 5:15 tomorrow morning. I will need to leave the house by 4am. I guess I will need to get up around 3 so I can shower with the special surgical scrub wash they gave me to shower with on the night before and morning of surgery. Sleep tonight is immaterial because I know I wouldn't sleep tonight anyway. Hoping for the best .... see you all on the other side (God how I've longed to finally say that!!!)
May 4, 2004 - I went for follow-up and staple removal today. After 11 days, I'm down 17 lbs (248). I'm feeling very good especially considering that I've been through major surgery. I can now start a soft diet ... no meat. I will be able to start fish on 5/11 and chicken on 5/18 and beef/pork on 5/25. I'm feeling great with no regrets so far.
July 13, 2004 - I feel that I'm doing wonderful. I haven't had any problems. I have only felt nauseous two times. The first time was peanut butter on a few low fat crackers. I guess the peanut butter was too fatty. The second time was when I had some coconut shrimp. I didn't even use the pina colada dipping sauce, but I guess the coconut was sweetened. I started feeling nauseous within about 20 minutes of eating and it lasted for about 40 minutes. It was miserable. I'm down 47 lbs now (218). I feel alot better about myself. I'm not so embarrassed to go out. I definitely have more energy and don't get out of breath near as fast. This has been the best thing I have ever done ... pretty much without exception.
December, 2005 - Had double you over abdominal pain. It was awful. Went to the emergency room. They did a CAT scan. The doctor asked if I had been constipated and told him I was as regular as clock work on a daily basis. After the CAT scan results the ER doctor came in and said he was prescribing me some pain killers and a stool softener because he was diagnosing me with constipation.....I asked him how I could be constipated when I have a bowel movement daily...he had no answer. My CAT scan results were forwarded to my surgeon's office. My surgeon recognized the swirl on the scan as an indicator that I had a hernia. I was scheduled for exploratory surgery. It turned out that I had a double internal hernia (so there was no noticeable bulge). My surgeon said that 80% of my intestine and slipped through the hernia and it could have been VERY bad. Had the blood supply been cut or severly hindered then I would probably have had to have most of my intestines removed. Thank goodness the ER sent my scan to my surgeon because obviously they were idiots!!! Surgery went well and recovery wasn't bad.
December, 2006 - Doing fine. I have gained about 5-10 pounds over the last year. I need to re-evaluate my diet and make sure I'm not eating inappropriate things. I also need to get back to exercising on a regular basis. These are my New Year's resolutions.
July, 2018 - Enough is enough! I have to get a handle on this weight creeping. I am convinced that, at least for me, carbs are the devil. I’m trying to follow the Keto diet and keep my net carbs <=20gms.
June 23, 2003...................272 (Highest Weight)
April 23, 2004...................265 (Date of Surgery)
May 23, 2004..........-26.....239.....41.0 (BMI)
June 23, 2004.........-12.....227.....39.0 (no longer qualify for surgery)
July 23, 2004..........-12.....215.....36.9
August 23, 2004........-7.....208.....35.7
Sept. 23, 2004.........-11.....197.....33.8
October 23, 2004.......-6.....191.....32.8
November 23, 2004 ...-8......183.....31.4
Dec. 23, 2004 .........-10......173.....29.7 (no longer considered obese)
January 23, 2004.......-8......165.....28.3
February 23, 2004......-3......162.....27.8
March 23, 2005..........-5......157.....26.9
April 23, 2005............-3......154.....26.4 ONE YEAR ANNIVERSARY !!!!
October 23, 2005................148
December, 2006.................156
February 23, 2017 .............189
January 7, 2018.................200
June 4, 2018 .....................204
July 3,2018.......................197.8
August 2, 2018..................188.2
September 4,2018..............183
September 24, 2018...........180.2....30.93
January 7, 2019.................178.8
January 21, 2019................173.2...29.73
