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Dr. Simon no longer participate with Aetna, so I've switched to Dr. Matthew A. Fitzer in New Hartford, NY.  My informational session and initial consult are scheduled for October 22, 2010.  I hope to have surgery in the first half of 2011.

My husband and I have taken jobs back in upstate NY.  We spent many years there and are happy to be going back.  My last day here in Mississippi is September 3; we were here for 3 years.  I had to drop all my fall classes.  I will miss the early springs here, but I'll be glad to see fall and, yes, even winter again!  It snows a ton up there.

I've chosen a new surgeon, Dr. Howard Simon, at Upstate Medical Center in Syracuse, NY and have contacted his office about joining his program.

I'll be very busy the next few months, getting the house ready for market, packing up, moving, changing kids' schools, etc.  So the time should go fast.  It will be December 4 before you know it, and I'll be fully qualified for surgery.  Except I still have to do that 3 month diet again for Aetna.  I'm hoping to see my new surgeon in late October and start the diet then. It's a pain starting all over but I'm glad to be going home.

It's 4 months later.

Aetna updated their Clinical Policy Bulletin "Obesity Surgery 0157" in April of this year.  They made some clarifications that helped clear up some uncertainties, such as:

- the 2 year weight history needs to cover the last 24 consecutive months
- the 3 month diet has to be done within 6 months of surgery, so I have to do another one
- the 3 month diet has to be 90 days long exactly, not 88 or 89

Based on this, I've decided not to submit again until December.  My first weight was December 4, 2008 at 202 pounds and a BMI of 35.  So I qualify on December 4, 2010.  My weight currently is 262.  I'll redo the diet  August - November this year and really work hard to get ready for surgery. 

I went back to school in the evenings and just completed my first semester with straight As.  It is really helpting to keep my mind off the wait.  I'm taking 2 summer classes, then starting the fall semester in August, and when that's done I will have already submitted.  It's less than 7 months, really!

Well, it's 2010 finally!  Maybe I'll get to have surgery this year.  It could be early next year, but I'm trying to stay positive.  I'll call the insurance person at my surgeon's office in March and see when she wants to submit again this year.  Maybe I can talk her into June.  To pass the time, I've gone back to college.

Good news, it's almost 2010!  Yayyy.

I'm trying to decide WHEN to submit to Aetna again for surgery (second try).  Since my first qualifying weight was in December of 2008, do I have to wait all the way to December of 2010?  Or can I submit within the appeal window (180 days), hoping they'll approve knowing I'll just appeal?

The kicker is that if denied again, I have to wait another 6 months to re-submit.

I'm thinking June 10, 2010, which is just within the 180 day mark.  And if denied I can submit again in December 2010 as I had previously planned...

Got word today that Aetna denied me because I don't have the 2 year weight history.  Of course, they are correct, I don't, so I can't appeal.  The only thing I can do is wait until I DO have the 2 years they require and try again.

We're going to try again in April 2010 (in 6 months) in case they want weights in 3 calendar years (2008, 2009, 2010).  If they deny again, we'll try again in December 2010, which will give me 24 months of weight history (December 08 to December 10).  I'll have them for sure at that point!  It's only 14 months to wait at the maximum.  Some people wait years to get their surgery.

I'll see my dietician monthly and the physician periodically to keep my weight history stream going.  I finished the 6 month diet April - September of this year, so that fulfills the supervised diet requirement for 2 years.  All set there.

Just kind of bummed out!

After a couple phone calls back and forth between me/Phyllis and me/Aetna, Aetna has finally confirmed that they have me in for pre-authorization as of October 1.  So I should know something shortly.  I am thinking positive, like Phyllis told me!!

We submit to insurance on September 25.  I'm in the pile, just waiting for Phyllis to get to me.  She and I talked it over after my appt with Dr. Low yesterday and we decided to go ahead and submit even though I'm a short on the weight history.  Phyllis said sometime they mess up a bit and approve things you never think they would.  She insisted that I think positive so that's what I'm doing.  I WILL be approved!  I'm really heavy in the supervised diet category and that is where they usually focus since that is where most people are deficient.  So please pray for me.

I'll update after I hear.  I have no more appts with the doctors, we're just coasting till approval.  I'll still see my dietician monthly though.  After I'm approved, I have 7 weeks of pre-op education classes to attend before surgery.  I also have to go back to my PCP to get him on board, he still thinks I'm doing lapband and he's the one that schedules my pre-op testing.  I need a letter of medical release for surgery from him.  I've typed it up already, cribbed off the internet.  Once approved, I'll go see him and get that ball rolling.  I'm really hoping to have surgery in December.  I hope to have some good news soon!!

I saw Dr. Low today.  I am ready to see the surgeon next month (September) as far as she is concerned and begin my pre-op stuff.  But then I talked with the insurance coordinator (Phyllis) and she does not see any way I would be approved by Aetna for surgery this year.  They require 24 months of weight history and I don't have it.  So I could have to wait as long as December 2010 for surgery...18 months from now!  But we'll try again as soon as January 2010 gets here.  Then I'll have weights in Dec 2008, all of 2009, and Jan 2010.  If I did all the pre-op stuff in December maybe I could have surgery in January.  That's only 5 months.  Some people wait years and years so I'm trying not to feel sorry for myself.  What really scares me is the socialist health care reform this idiot president is trying to force down our throats.  There is a 5-year waiting list for this surgery in Canada and there's no way I want any part of that.

Phyllis didn't have my PCP medical records so I stopped there and put in the request to fax them.  It may take a week for the doctor to sign off on them and get them over.  After the records are received, it will take a few days for the insurance coordinator to compile the request and send it in.  Then Aetna takes about a month to respond.  Once they deny me, then we will figure out where to go from there.  I figure that puts me into early October.

Good news is I finished the 3 month diet and by the time next month rolls around, I'll have finished the 6 months as well so that covers me as far as the physician supervised diet goes for 2 years.

So now I'm just waiting on my denial...what a bummer!

I weighed in with my dietician on August 11 and weighed 230, down 16 pounds now.  I can't lose much more since 226 equals a 40 BMI and I just don't want to take any risks falling below the weight requirement.  I know I'll lose more on the pre-op diet once I have insurance approval.

I checked and the surgeon's office received my psych eval.  I called Aetna and they have nothing in the system for me, but the insurance person at the surgeon's office (Phyllis) is on vacation.  She probably didn't get a chance to submit me before she went.  She'll be back on Monday and on Tuesday I have an appt with Dr. Low.  I was hoping to have an answer from Aetna by then, but instead I'll talk to her about submitting and the plan if we have to wait until January.  I typed up a one page summary outlining how I meet Aetna's criteria for surgery and I revised it today so I'll be glad they'll have the new one anyway.  I also want to give them the 3 dates I met with the exercise therapist in case Aetna decides my Ph. D. dietician isn't a "qualifed professional" for the required exercise regimen.  I'm trying to cover all my bases, but I do believe at this point that I will end up moving surgery out to January 2010 to round out my weight history for Aetna.