Aimee F.

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Post Date: 10/12/08 4:20 pm
Well, just over 3 weeks until my surgery!  Yay!

I'm not really freaking out entirely - I have so much to do before I can relax for surgery.

I'm self employed, and have been for 3 years, so I'm a little nervous about handing the reins of the business over to my staff for the 4 days I'm planning on being out.  (I'm not going back to "work" right away, but expect that I will spend some time answering emails and handling calls etc.  Probably not more than half an hour at a time.)

I'm going to a conference in two weeks - I just launched a new product for my business which I've been working on for a year.  Finally getting it done was a goal over the summer, and then getting it done before the official launch at the conference was urgent (I had to buy the booth for the conference months ago, hoping I could get it done in time!)  So that's been a major stressor.

Then, in August, I started another new business - my husband was laid off and we decided to take our savings and invest it in a new start up.  This way, we would get the return on our money, and my husband would have an income stream.   Our one employee quit with no notice on Wenesday!  So, we're in the process of trying to get another "body" in place to help with the admin stuff etc. 

And to top it all off, my 4 year old son was kicked out of his day care on Friday!  He locked the day care lady out of her house then laughed about it and wouldn't let her in.  It seems like this is really her problem, since she was outwitted by a 4 year old, but she won't have him back.  So we have to find a new place for him.

So, I decided to "treat" myself by going to the spa on Friday and getting a massage - I got a coupon in the mail from my favorite spa place, so I decided to go since I had gotten so much work done.  All was well - I had my massage, was very limp and relaxed.  I sat in the whirlpool for a while, then got out to go sit in the cool mist room.  As I turned to close the door, I slipped on the tile, and fell, *splat* on my left side.   I have horrible bruising on my arm, leg and left boob (My boob got smushed when I landed in the door frame of the mist room.)

My week has sucked spectacularly.

It can only get better right???  I'm a giant stress monkey right now and haven't made ANY preparations for surgery.  I don't even know what I really need to do.  I plan on laying in a stash of protein friendly soft foods.  I had emailed Vitalady about protein, but still haven't gotten any samples picked (I had hoped they would just send me some, but apparently I have to pick them out myself - which is not really very helfpul.)

I have my pre-op vitamin regime started.

What else is there?  I've read and read and read the "2 week freak" threads around here, but I feel like I'm missing something major that is so obvious that no one has mentioned it because you must be brain dead if you don't know it!  :)

Thanks for reading....

Post Date: 9/26/08 4:44 pm
Okay, after all these months of waiting, things have finally swung into action!

My surgery date is November 5th!

Yay!  Just over 1 month!

I have got to keep busy to fly through this month!

I can't believe I went from NOTHING on Monday to having a date on Friday!

Whoo hoo!!!!!

Well, the DMHC called me today to say that Anthem had AUTHORIZED my surgery!

Yay!

18 months of fighting done!

WHOOPPPEEEEEE!!!!!

I can't believe it - I'm still in shock.

Hopefully I will have a date soon!

Thanks, and have a great weekend everyone!  I know I will for certain!

I'm just jumping up and down with joy!

Here's my saga in a nutshell:  Anthem/Blue Cross denied my request for authorization to see Dr. Crookes because he is out of network, but agreed that I qualified for bariatric sugery, and instead referred me to Dr. Krahn, the in-network bariatric surgeon, who only does RNY and Bands.   I appealed.  BC denied me because they said the DS was only for BMI >60.  I initiated the IMR process with the Department of Managed Healthcare (the Calfornia entity that watches over the HMOs here.)

The DMHC calls me and says, Blue Cross tells us that Dr. Krahn performs the DS.  You have to go see him.  I was soo frustrated, but I made the appointment.  He was on vacation for a while, and of course backed up, but I finally had my appointment today.

So, after going through the song and dance of new patient (blood pressure, weight etc.) we meet with his PA to go over medical history.  We had a nice short discussion in which I informed him that I was only interested in the DS because of my severe extreme diabetes.  He said, okay we'll cut this short and you can see Dr. Krahn.

Dr. Krahn is a really super nice man.  If I were getting an RNY, he would be an excellent choice, no doubt about it.  He said when I walked in, oh you must be the patient that the insurance company called me about. (!!!)

He said that the reason the insurance wanted me to see him was to make sure that I understood all the risks of both procedures.   [Personally, I suspect they wanted him to take a crack at selling me the RNY.]  We had an interesting discussion, in which he said that he didn't agree with Buchwald's numbers (that RNY cure rate for diabetes was 90%, and I didn't even mention to him the weight re-gain and diabetes that emerges again with it.)

Long story short, he said he didn't do the DS.  And he said, in fairness, even if I did, you wouldn't want me since I am not an expert in it.  I will call the health plan and tell them to authorize you to see Dr. Crookes!

So, he wrote out this note on my chart, gave me a copy, and said he would call the IPA today. 

I am not sure if I will get the authorization or not, but the final piece that was keeping me from the IMR is done at any rate, so either way, it looks like I'll be getting it soon.

YIPPEEE!!!!!!!!!!!!!  I've been actively fighting since March, and initially requested bariatric surgery more than 14 months ago, so I'm hoping to have the surgery by Christmas!

Yay!

Although it was disappointing.

I was really thinking that Dr. Crookes would write something a little stronger than he sent me. The letter starts with the medical history, current meds etc. Then the reccomendations section:

"In conclusion, I would consider Momincorona to be a good candidate for surgery for her morbid obesity especially in light of her insulin-requiring diabetes. We had very extensive discussions at the time of this consultation about the optimal procedure. The patient and her husband are extremely motivated to request the Duodenal Switch procedure because of its demonstrated superiority in producing resolution of diabetes (cites the Buchwald study). We continued these discussions by telephone as well as a subsequent appointment in my office. On balance, afer weighing carefully teh risks and benefits and alternatives, we have concluded that the best procuedre for this patient is indeed the Duodenal Switch procedure. Resolution of diabetes cannot be guaranteed after any bariatric procedure, but the DS appears to have the high chance of inducing resolution. The patient is aware that the most critical factor in resultion of diabetes appears to be the duration of the disease."

I guess it's better than nothing. I am going to write a stronger letter to BC/Anthem - the letter I wrote to the DMHC was pretty weak, which is what they submitted on my behalf to BC.

What really chaps my hide is that this letter is dated 4/23 - the date of my initial consult with Dr. Crookes - and nearly 2 months ago!!!

Well, apparently I let myself be steamrolled by Dr. Crookes. I had a follow up appointment with him on Monday, 6/9, and convinced him that I have realistic expectations for the surgery and that it is appropriate for me to have. I just want the damn surgery already!

Based on the advice of some helpful OH members, I had initiated the process with DMHC anticipating a denial from BC when I got the letter of medical necessity from Dr. Crookes. Well, what I didn't realize was that when the DMHC got my appeal, they initiated the appeal with BC. So I got a letter from Blue Cross saying, hey we got your appeal you have until 5/30 to send in supporting documents. I had to call them and ask for an extension since my appointment with Dr. Crookes wasn't until after their deadline!

Part of this confusion was because I had talked to Dr. Crookes on the phone after my initial appointment, and told him I definitely wanted the DS, and he said, okay, I'll write you a letter, but when I followed up with his office, I was told he had to see me again...

Anyway, we had our second consult ($72 later), and I am waiting for a release form from him acknowledging the risks, and then he will send the letter.

Once we get that letter, hopefully, BC will respond quickly. Otherwise, we have will have to appeal to the DMHC.

The other problem is that my husband was laid off and we still don't know what our COBRA payments will be to continue insurance. If we get a family policy on our own it will cost us $1,000/month. Our payment through his company was $500/ month before, so it doubles the cost, if it's the same.

If nothing else, we will scrape enough $$ together to pay until at least we get through the appeals process. If I have to get another policy, there is usually a 6 month waiting period for any "pre existing conditions" and I suspect WLS would fall under that category. So, hopefully it will happen sooner rather than later.

Well, I finally got my consult with Dr. Crookes today.

I paid out of pocket for my consult since my insurance only approved me for a consult with a RNY/Lap surgeon. I wanted the DS, and had hoped that Dr. Crookes would write me a letter of medical necessity since he was out of network.

Well, we talked - he is so wonderful. However, he looked me straight in the eye and said, there would be no benefit to me to get the DS versus the RNY.

He said that I would be happy with the RNY, that it had about the same cure rate with diabetes (he even talked about the Buchwald study) and said that maybe, statistically, the DS would increase my chances of a cure by maybe 1-2%, and that it wasn't worth the fight to get it.

This comes on top of my husband finding out on Monday that he will be laid off in 6 weeks. So, it looks like if I'm going to get any surgery at all, it will be the RNY, as long as I can do it before our insurance runs out (although with COBRA we should be able to keep it at least through summer before we run out of money for it.)

I'm very sad. I had thought Dr. Crookes would be open to letting me have the DS. He said, hey I have no reason to NOT have you do the DS - I love doing it.
But it's an open procedure with additional risks etc. He said that if there was a medical reason for me to have it, he would absolutely recommend it, but there isn't one.

I called Dr. Krahn's office today - the "seminar" was yesterday and the next one isn't until the middle of May, which seriously eats into my insured time - they are going to mail me the "packet" and once they have that, they will schedule my consult with him.

So I'm sad and excited.

Well, it was denied.

When I got hold of the referral coordinator, she said it was denied because I didn't meet the criteria. So I called the management company, who told me they couldn't tell me the criteria over the phone, but would mail it to me. It sounds like just so much bullshit. Its not protected information - and I"m the freaking patient.

So then, I went to pick up the copy of the denial from the Dr. office, I actually read it, and it says it was denied because Dr. Crookes isn't "in network." So I call up the management company again to find out if there is someone "in network" who does the DS. Well the lady on the phone, although very nice, didn't have two brain cells to rub together. What it boils down to is they only want to refer me to their in-network doctor, even if he doesn't do the surgery I need.

So I call Blue Cross, and basically am told that I would have to get a letter of medical necessity to force the IPA to go out of network. Fortunately, I had already made my appt. with Dr. Crookes so hopefully he can write that letter for me.

The other crazy thing is that the IPA referred me to Dr. Krahn of Western Bariatrics for Lapband, of all things. Clearly the IPA has no concept of which surgery is appropriate for which patients. I think if I went to Dr. Krahn, I could get the RNY, but I really, really, want the DS. I called his office and his office assistant had no idea what DS was. She thought I was talking about a panni. I had to laugh, because Dr. Krahn's website discusses DS!

I was thinking I could avoid the $350 consult fee with Dr. Crookes if I went to Dr. Krahn and asked him to write the letter for me (assuming he would agree that DS is the right surgery, but if he thought that, why isn't he offering it?) and there is such a long load of BS stuff you have to do to even get the consult with him! They make you go to an informational seminar first, and they only offer it once a month, and it is at 6:30 on a Tuesday evening... I told her that I had already been to a different doctor seminar (Dr. Crookes') and she told me it didn't matter. And even though I don't want the surgery from Dr. Krahn, I STILL had to sit through this seminar...

Oy!

Anyway, I'm going to see Dr. Crookes on Monday and hopefully he will make everything okay.

This is going to be a very long wait!

Well today I called the doc's office to see if there was any word back from the IPA or anything needed from me to expedite my request.

The referral coordinator checked the computer and told me that my request was with the Medical Director already and that was great news since she said it usually takes 6-7 "back and forth" to get to this step.

She said I would definitely know by Wednesday.

Tomorrow is going to be a very, very long day.

April 2, 2008

To Whom It May Concern:

This letter is to request a referral for a consult for biliopancreatic diversion with duodenal switch (BPD-DS) surgery, a type of bariatric surgery which will put my NIDDM into complete remission independent of the weight loss it will induce.   I am requesting a consult with Dr. Peter Crookes, MD, FRCS, FACS, at the Bariatric Surgery Center at the University of Southern California .  Attached is Dr. Crookes’ curriculum vita.  

My primary care physician, Dr.Z, initially requested a bariatric surgeon consultation in the summer of 2007, at which time my referral was denied until the requirement of a 6-month doctor supervised weight loss program was met. I have been overweight my entire life: attached is a doctor’s report from when I was 5 years old indicating I was overweight – the notes say “healthy, heavy.” I had gained 11 pounds in 14 months. In my adult life I have undertaken many, many diets, each time losing a small amount of weight, and then gaining it back, plus additional weight. See attached list “Weight Loss Programs Undertaken” for years, diets and the outcomes.

In 1998, I was diagnosed with NASH – non alcoholic steatohepatitis – via a liver biopsy, which is directly tied to obesity.

In 1999, I was diagnosed with NIDDM. I was started on oral medications and insulin. In 2002 and in 2003 I had successful pregnancies, but gained weight with each pregnancy as my insulin needs increased; additionally, both times I needed cesarean sections due to the size of my babies (8.6#s and 9#s).

I was finally put on an insulin pump in 2004 as my insulin needs kept increasing – when I was finally taken off the pump in 2007, I was using over 150 units of insulin daily, and gaining weight rapidly.

In 2007, the pump was stopped because of my continued weight gain, and a new class of oral drugs was started (Januvia) in conjunction with Actos and Glutmetza. My blood sugar is very poorly controlled with these drugs, and I am adding insulin back into my regime.

Standard weight loss is impossible for me metabolically. Additionally, there is no clinical evidence that weight loss before bariatric surgery is necessary. In fact, the California Department of Managed Health Care has issued a study Review of Weight Loss Prior to Bariatric Surgery which states “Mandated weight loss prior to indicated bariatric surgery is without evidence-based support. Mandated weight loss prior to indicated bariatric surgery leaves the patient at increased risk from the patient’s comorbidities. Mandated weight loss prior to indicated bariatric surgery is not medically necessary. Mandated weight loss prior to indicated bariatric surgery would be deviant from the standard of care practiced in the United States and other published countries. The risks of delaying bariatric surgery, while not entirely known in the short-term, are real and can be measured. Any potential value of losing weight prior to bariatric surgery is theoretical and not supported by any data.” The full text of this study is attached.

In addition, I am requesting BPD-DS surgery because it will have a better long term effect on my NIDDM – the most commonly done bariatric surgery, RNY, has a lower rate of remission of NIDDM for longer-term diagnosed patients than BPD-DS. “Both RYGBP [Roux-en-Y Gastric Bypass] and BPD were safe and effective procedures when offered to non-superobese patients. Weight loss after BPD was consistently better than that after RYGBP, as was the resolution of diabetes and hypercholesterolemia” (Obesity Surgery. 2006 Apr;16(4):488-95.)

BPD-DS will also have a beneficial effect on NASH: “DS improves both hepatic steatosis and its resulting inflammation.” (Obesity Surgery. 2005 Nov-Dec;15(10):1418-23.

Lastly, although the clinical data show that BPD-DS and RNY have similar mortality and complication rates, because the BPD-DS does not alter the main anatomy of the stomach, there is less dietary restriction and therefore greater compliance with post-surgical requirements resulting in longer-lasting weight loss.

Also attached to this letter are some additional studies which discuss the benefits of the BPD-DS surgery.

Roux-en-Y gastric bypass versus a variant of biliopancreatic diversion in a nonsuperobese population: prospective comparison of the efficacy and the incidence of metabolic deficiencies. Obes Surg. 2006 Apr;16(4):488-95.

Duodenal switch has no detrimental effects on hepatic function and improves hepatic steatohepatitis after 6 months. Obes Surg. 2005 Nov-Dec;15(10):1418-23.

Patients Who are Delayed from Undergoing Bariatric Surgery Do Not have Improved Weight Loss. Obes Surg. 2008 Mar;18(3):278-81. Epub 2008 Jan 19.

Comparison of effects of gastric bypass and biliopancreatic diversion with duodenal switch on weight loss and body composition 1-2 years after surgery. Surg Obes Relat Dis. 2007 Jan-Feb;3(1):31-6. Epub 2006 Nov 20.

Long-term control of type 2 diabetes mellitus and the other major components of the metabolic syndrome after biliopancreatic diversion in patients with BMI < 35 kg/m2. Obes Surg. 2007 Feb;17(2):193-4.

Restoration of acute insulin response in T2DM subjects 1 month after biliopancreatic diversion. Obesity (Silver Spring). 2008 Jan;16(1):77-81.

Duodenal Switch: Long-Term Results. Obes Surg. 2008 Mar 12 [Epub ahead of print]

Thank you very much in advance for your assistance with this matter. Please feel free to contact me if you need additional information.

Regards,