lisakmcb
*I have posted a before picture, and hope to eventually post an after picture.........only time will tell.*
I am 40 years old, 5'6", 261 lbs, BMI 42. I have never been this heavy in my life, not even at 9 months pregnant, and Im still gaining! I feel like I have been carrying a baby elephant for 15 years. "Hello, you can come out now. Seems that baby elephants are carried for 1.5 years not 15. Oops, my bad!"
12/30/2005 Received paperwork from a local doctor, Dr. Champion, and will get the insurance approval process rolling just in case there is some way around Aetna's exclusion of 'any treatment of obesity'. After reading the policy manual again, it actually states "except when specifically approved by HMO". So, maybe there is hope afterall. My BMI is 42, and I have a few comorbidities: high blood pressure, joint pain, and depression - geez, who doesnt nowdays, right- which combined makes me a good candidate from what I understand. I wasnt an overweight child, and my first 2 children didnt put any extra weight on me after their births. However, at ages 25 & 29, my third and fourth pregnancies were not so kind. I have continued to gain weight pretty steadily since, despite diets, diet pills, walking, working out, and anything else that I have forgotten about. So, here i am, hoping to become a BIG LOSER in the new year. Wish me luck!!
1/2/2006 Ok, thought I was going to get a jump on it first thing this morning, only to find that the Dr's office and the precert and member services departments of the insurance company are still closed for the holidays. I will try again tomorrow. I did review the policy manual again and found an 'amended exclusion' to the weight loss surgery that once again excludes it, but will keep trying until I get a DENIAL in black and white. I am determined to get this done and hopefully paid for by Aetna. By the way, to anyone who happens across my profile, I have found lots of inspiration to persue this and to expect great results by reading the profiles of those who have gone before me and been successful. There is a lot of really helpful information on this websight, and I am thankful that someone started it and cares enough to keep it up and running!
1/3/2006 Got in touch with the insurance company this morning. There is an exclusion in place for "anything weight related", supposedly chosen by the city manager when the contract was negotiated. My husband spoke with the city manager, and he is checking into why this was put into place, as he claims no knowledge of any such exclusion. The contact person at Aetna claims to also have no knowledge of why the exclusion was added, but is looking into it. Hopefully I will have an answer to wether it can be corrected and if so when, within a few days.
1/6/2006 Ok, this makes absolutely no sense. First the Aetna contact person, who is actually only a broker, tells the city manager that she also has no explanation for why bariatrics was excluded from our policy and that he HAD to have made that choice on his own. Then the next day she faxes him a letter that states that policies with 51 or less members automatically have a bariatric exclusion to their policy. Shes a smart one, eh. Meanwhile, I am contacting Aetna to get addresses and fax numbers of which department to send my letter to, and explain the situation as to why I need to send one, and they are telling me - as they review my policy in their computer system - that the city manager needs to put in writing that he wasnt given the choice, and that if he had he would not have excluded bariatrics from our policy. Ok, what part of this am I supposed to understand. Both people weve talked to are telling a different story about why we dont have coverage, wether or not we can get coverage, and what we can do about it. I think my next move is going to have to be choosing and consulting with a surgeon and having them make the request, and forcing Aetna to make a determination. Once again, wish me luck! Oh, and today my weight was 262. Another pleasant suprise, NOT!!!!
1/10/2006 Saw my PCP today to begin the paper trail that Aetna will require at some point if they approve. He wrote me a medical necessity letter, and suggested a surgeon that is IN network with Aetna, just in case. My weight today was 254. Not sure how that happened, but I assume it had something to do with the fact that we did some early spring cleaning sunday, and I either sweat it out or just plain dehydrated myself to some degree, plus weve all had a cold for the past 2 weeks, so that probably factored in also. Either way, since apparently most surgeons expect you to loose a little before surgery, I am a step ahead of the game. Just hope it holds out till then. I am trying to stay optomistic about this whole process, and I'm doing ok so far, but the more I think about the burden it would put on my family, and the fact that its just not feasible for our budget, I know that if insurance doesnt pay I wont be having this procedure. I will keep up hope though that they will!
1/15/2006 No new news yet. I called the Dr. my PCP referred me to, a Dr. C. Daniel Smith, who is with Emory Crawford Long Hospital, and scheduled to attend their next seminar which is in February, and is a requirement of the process.
1/26/2006 Faxed my information, as well as medical necessity letter from my PCP, to Aetna on the 18th. 7 pages total. They have received it, but have not reviewed it yet. Scheduled to attend a seminar with Dr. Scott in Rome tonight from 6-8pm. Want to check out a couple of surgeons before choosing one, but ultimitately it will come down to who Aetna considers IN network, or is willing to pay as if they were in network. I have heard positive things about Dr. Scott from local people as l well as on the website. I hope this seminar gives me new hope and lots of useful information. I'll post again when I know more. Im not giving up yet!
Much thanks and lotsa love to my bestest friend Teresa for all of her love and support! (and by the way, we did not 'steal' her momma's car when we were 14, and are innocent until proven guilty in a court of law...LOL)
1/27/2006 Ok, I went to Dr. Scott's seminar last night. He seems very knowledgeable, and has a great personality, which I hear some WL surgeons lack. His presentation was very informative, and I learned a lot. I also learned that insurance companies with exclusions and exclusions to exclusions generally do not pay no matter how medically necessary, but Im not giving up yet. I will fill out the patient information sheet and fax it in along with copies of what I have already sent to Aetna myself. Who knows, maybe I'll slip through a crack. Dr. Scott also suggests for those who are self pay, that home equity loans are the best way to go if you must borrow the money, as you will get the low interest rates that home loans are getting nowdays, and the loan will be tax deductible. Still dont know if that will be an option for us. It would depend on the payment amount of the loan. I will be starting a job working saturdays this weekend, so maybe that job alone would cover the payment. Hmmm, something to think about.
2/1/2006 Nothing new so far today. I hope to hear something from either Dr. Scott's office or from Aetna soon so that I dont go to this other seminar unnecessarily. I would much rather stay as locally as I can if we can get approval to use him. As of yesterday my weight was 150. As much as I like seeing that number drop, I hope that IF this all gets approved, Im not below the BMI I need to be at to qualify. My PCP also suggests that the Adderall I have been taking since December may be responsible. If thats the case, hook up an I.V. and let it flow!! It would make some sense, I havent had much of an appetite for quite awhile. Some mental hunger, and a little boredom hunger, but no stomach growling hunger. I still eat 2-3 meals a day, but I dont eat much, and I dont have cravings for anything. Occaisionally there are days when I only eat once, but I think its dependent on what time I take the Adderall. I've been taking 1/2 instead of 1 whole pill, because a whole pill makes me nauseous and nervous, and I have a hard time getting to sleep if I take it at any later than lunch time. I think I may call around today to see if there is any change in status. If so I will post it.
2/6/2006 Still haven't been able to reach the bariatric coordinator in Dr. Scott's office. Called several times, left 1 message, but no return call so far. Called again today and left a message with a live person, and apparently the bariatric coordinator has been out and will return tomorrow. Maybe she's just had this flu thats been going around. So, hopefully she will call tomorrow, if for nothing more than to let me know that they received the paperwork I faxed the week before last. Since the department at the insurance company that handle's reviews and approvals is behind in reviewing, I will wait a little longer before I call them again. Trying not to get too impatient and let things happen in the time that it takes. It's hard to do when you're waiting to change your life. Im trying to make little changes along the way also, so that Im where I need to be when the time comes for the changes to take place. Wish me luck, and patience!
2/10/2006 Nothing new to report regarding surgery or insurance. The bariatric coordinator for Dr. Scott's office, Ginger, finally returned my call yesterday. She doesnt appear to have a very patient oriented attitude, and seemed a little annoyed that I had called at all. I left well explained messages, as well as asked her when she called, whether they had received the papers I had faxed, and what the next step was. Her reply was that she handed out a sheet at the seminar that listed what the steps were, and that I should read it. (What the...?!) She didnt answer as to whether or not my fax had been received, and as for the paper she handed out.... it plainly said that within a week of filling out and returning the patient history, they would call to schedule a date for a consultation. So, lets see, by my calculations it's been TWO weeks, so what exactly did I do that warranted the attitude she gave over the phone?! Maybe the Dr. himself would like to answer that question, although I doubt such a message would ever reach him. But, at some point, if I am approved, I will have to meet him in person.........
2/12/06 Called Aetna first thing this morning, and it's still in review status. Does that mean they are reviewing it, or that they have it but havent reviewed it yet?? No one there can answer that question. "Could be up to 30 days" is all they will tell me. I wont bother to call Dr. Scott's office again until I hear from Aetna. Nothing they can do at this point. I wonder if they will even hold on to my paperwork while Im waiting. Good thing I faxed it instead of mailing it, just in case. Our wedding anniversary is Valentines Day, and since my husband is out of town for the week, we celebrated this past saturday night instead. We went to Ruth's Chris Steak House in Buckhead, and it was awesome. Probably the best steak (and lobster tail) we've ever had. We try to have a date night now and then without the kids, but he works weekend nights, so it's hard. Im just glad his weekday schedule is days now instead of nights, so we at least have him home a few nights a week. Well, I dont guess there's anything for me to do right now regarding surgery, so I will continue to wait.....and wait.....and wait
2/15/06 Weighed myself on an upright Dr.'s scale yesterday and it said 247! Im not complaining, but whats up with that?!
2/21/06 Called Aetna again today. Member services states that on 2/6/06 a determination was made that there was not enough information provided. I sent them 7 pages of information, how could that be possible?? And why did they tell me on 2/12/06 that is was still in the review process?? What a bunch of shiesters!! I read posts on insurance companies pulling things like this, so I should have expected it. I asked why I hadnt heard anything or gotten a request for more information, and get this, they dont contact members! Apparently they dont notify anyone, as my PCP was not aware of this either. And I cant see a surgeon until I know whether they will pay them or not. I have already sent one request for assistance to the state insurance comissioner about the original issue of exclusion, and I may send another regarding this new info. I assume this is all a part of their waiting game, as you only have so long and so many tries to get approval, and they dont let you know anything in a timely manner. I'll post again when the steam stops coming out of my ears and fogging my monitor!!
2/22/06 Have a consultation appointment with a surgeon next week (Dr. Macik). Have seen his name on the BH website and read good things about him there. Have also spoken to a few of his patients from the website who all confirm his competency and skill. Have heard nothing negative about him. So far his office is the only one who seems to be willing to start the process, going on the information I have given them about Aetna. Keeping in mind that I am working with an unknown deadline, as you only have so long to get all the information in once a case file is opened, and only have so many tries for approval. Hopefully they will be able to get Aetna to do what we need them to do. They appear to appreciate each individual patient and their particular circumstances.
3/1/06 Met with Dr. Macik and his assistant today. They are going to get a letter out to Aetna, and hopefully provide the rest of the information that Aetna requires. We will see if this gets us where we need to be. They were both very nice, and seemed genuinely interested in helping me deal with Aetna. I'll keep my fingers crossed.
3/13/06 Well, so much for first impressions. In 2 days it will have been 2 full weeks since my consultation with Dr. Macik. I have waited patiently to hear from them, but decided today that I would check with Aetna and Dr. Macik's office for an update. According to Aetna they have received no information or correspondence whatsoever from Dr. Macik's office. This is very disappointing news, so I call his office to see whats going on. 'Tiffany' verifies that no letter has been sent, and that it wont until I have completed a psych eval and seen a dietician. 'Tiffany' also cannot explain why in 2 weeks no one from their office has bothered to contact me with this information. I explained to her that I am very disappointed and upset by this, as I explained in full at my consultation that my situation was being handled differently with Aetna, and that these things were not required at this time. Why is there no followup system in place in this surgeons office???? Who is accountable for making sure that what needs to be done is done???? I prepared and faxed a 2 page letter to Dr. Macik today asking that he "please allow me the courtesy of letting me know as soon as possible whether or not his office will be assisting me in this matter." I deserve at least that much dont I???
I will post again when and if I get a response. If I havent heard something by the end of this week, I will seek another surgeon.
3/13/06 As of today I have heard nothing from Dr. Macik's office. I cannot get through to them by phone, each call goes directly to an answering service. Per Aetna nothing has been received from Dr. Macik's office. Time to move on.
4/10/06 Received rejection letter from Aetna today. Reason for rejection: This is not a covered benefit. So, in essence I have wasted 4 months waiting for something they could have told me on day one instead of doing as Aetna themselves suggested I do and waste my time with letters, seminars, and consultations. I guess this is the end of my story here on OH.com. If nothing else, I hope anyone who reads this will at least take this much from it: Dont waste time with any doctor who has bad references or bad posts. Dont bother going to a doctor who isnt fairly local unless your insurance demands it. Keep each and every letter or document you can get a copy of, and log dates and times of phone conversations. I have gone from 260 in december, to 239 currently. I will continue to keep working on this on my own and in the mean time will let Aetna continue to cover my doctor visits and medications for high blood pressure, depression, & plantar fascitis.
6/25/06 No update, just a weight check in. 230lbs.