YankeeRose
This was copied from my old OH profile
I am 5'1", I weigh approximately 344 lbs. (and continue to gain). I have PCOS (poly-cystic ovarian syndrome), hypo-thyroidism, high cholesterol, GERD, and I have insulin resistance. I am in constant pain - back aches, knees, legs, ankles and feet pain. I have bone spurs on the heels of my feet. I was just recently diagnosed with Obstructive Sleep Apnea so i don't sleep well and I am always tired. I also have issues with mild depression. Everyday living has become difficult for me. I have trouble putting my shoes and socks on, fitting into certain chairs, having seatbelts fit me, personal hygiene issues, sitting in booths at restaurants, etc. I am tired all the time and often feel depressed. I have tried every diet known to man (just about) and can't seem to lose the weight. If I lose any I always gain it back plus some! I am married and want to have children but have infertility problems/menstrual irregularities. I am hoping to be approved for WLS and be able to lose all this extra weight and be able to get my health and my life back. I miss living.
4/21/05 Well, I called my insurance co., BCBS of Tennessee PPO, and they told me I have a definite exclusion on my policy to WLS! So, I called my employer's benefits coordinator (I did not want to do this because I work for a relatively small company and the benefits coordinator is the owner's wife!) But, I called her anyways to ask about the exclusion. She told me she did not feel comfortable talking to me about this issue (WLS) and referred me to our company's insurance broker who she said has had WLS and could probably help me. So, I called the broker who informed me that she did have WLS and also has BCBS insurance. She also told me that the exclusion to WLS was a standard exclusion on all BCBS policies and that there was not a separate rider that my employer could purchase to override the exclusion (I asked about that). She told me she was approved in a matter of weeks by attending a WLS seminar at Centennial Medical center and then they handled all her paperwork with BCBS. So that is what she suggested I do, attend the seminar and submit my paperwork. She made it sound like if I could prove it was medically necessary for me to have WLS, that BCBS would probably approve it despite the "exclusion." So, this is what I am going to do. I am scheduled to attend a free WLS seminar on Tuesday 4/26/05 at Centennial Medical Center in Nashville, TN. I pray to God that I will be approved for WLS. I really hope she wasn't sending me on a wild goose hunt but I don't understand why there is the exclusion if you only have to prove medical necessity (the exclusion doesn't state that)?!? Oh well. Guess I will soon find out. But I am prepared and determined to fight them every step of the way if I have to because I NEED this surgery. I will post more later.
4/27/05 Hello again. My husband and I attended a very informative seminar about weight loss surgery at Centennial Medical Center last night. I was feeling very optimistic last night and felt like my husband finally "got it." Don't get me wrong, he has always supported me and my decision to have WLS, but I don't think he truly understood until last night. Thank God. Dr. Dyers nurse, Pam, told me I should check with my employer to find out if we have a self funded plan due to the exclusion on my policy. She said if it was self funded, we would have a better chance at over riding the exclusion. Otherwise, the outcome didn't look as good because she said it was a definite exclusion. I kept my hopes up that we were self funded because I felt so good last night I didn't want to spoil the mood. However, today I got the dreaded news. I found out today that my employer does not have a self funded insurance plan. We are fully insured, therefore, BCBS calls the shots and they say, NO SURGERY ALLOWED. Who made them GOD? Therefore, there is no way around the exclusion (or so they make me believe). They said that we have a small group policy which comes with a standard exclusion against WLS. But large group policies, like the one the State of TN employees have, covers WLS. That is so unfair! My husband says I should apply to work with the State (which I am considering) but why should I have to leave a job I love? I am so depressed now. I have been crying, eating, sleeping, fighting with my husband (because I am irritable and upset) and then crying, eating and sleeping some more ever since I got the news. What a viscious cycle. This is just so unfair. I feel like I am trapped and will continue to be trapped inside this body forever. I am sorry to sound so negative but I just needed to vent and figured y'all would understand. My husband (God Bless him, just doesn't seem to understand what I am feeling and although he trys to help, the things he says just upsets me more - like dieting and exercising because we all know that losing 200 lbs is sooo easy right? ) says I should keep fighting and that somehow we will figure out a way for me to have this surgery. If only it were that simple... Well, I'm gonna go for now or else I will just keep rambling on and on. Thanks for listening and God Bless.
| T | Tough |
| A | Accurate |
| M | Magical |
| M | Mystical |
| Y | Yucky |
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6/9/05 Well, I had my sleep study last night. I found out (unofficially) that I do have sleep apnea although I don't know how severe it is. My tech told me my oxygen level was like 80, whatever that means. (She said she's seen a lot worse). I kinda figured I had it but to hear that I do definitley have it is kinda scary and depressing. I have to go back next month to have the CPAP sleep level test, or whatever it's called. That scares me even more cuz I have heard horror stories about wearing that mask! I read one woman's profile who said she had severe panic attacks while trying to wear the mask becuz she felt like she was suffocating and felt restrained in that mask and not being able to breathe from your mouth. I am afraid I will also feel like that becuz I am somewhat claustrophobic and I also tend to breathe out of my mouth when I sleep. Also, I did NOT sleep well during the sleep study. I was so miserable and could not get comfortable becuz I felt restrained from all the wires. I am a restless sleeper anyways and toss and turn a lot and I couldn't do that with all of the wires attached to me so everytime I tried to roll over I woke myself up! Also, those things that go up your nose sucked!!! It bothered me so bad! They kept tickling my nose and making it itch! And I sleep either on my side or on my belly and I just could not get comfortable because those wires and tape would go up further in my nostrils and would rub up against there. It just really sucked and I am dreading having to go back for the CPAP test. Although the tech I had was great and really sweet and she really tried to help me to be comfortable. Oh and one more thing, my head was actually BLEEDING in the morning when she took off those wires! I wonder if this normal?!? Now my scalp is sore and tender where that thing was. I am sorry to sound so negative in this post but I know I am amongst friends here and just wanted to post my experience with this. A lot of people said the sleep study was a piece of cake and they slept like babies, but that was not the case for me. Plus I found the room to be stuffy. I found out in the morning that my tech was cold so she turned up the heat (I think she meant the AC so that it would shut off)! Can u imagine doing that in the midst of summer?!?!? Next time I might take a personal fan! Of course I am always hot anyways. Ok, now I am started to ramble so I will go for now. lol Thanks for reading! :-)
Until next time,
Tammy
6/15/05 Hello again. I was reading through my benefits handbook this morning when I came across a section about Case Management.This is what my policy said: "Under the case management program, the plan will identify members with potentially complicated medical needs, chronic illness and/or catastrophic illnesses or injuries that may be suited for alternative treatment plans. After evaluation of the member's condition, the plan may, at it's sole discretion, determine that alternative treatment is 'MEDICALLY NECESSARY' and 'APPROPRIATE.' In that event, notwithstanding any provision of this EOC to the contrary, the Plan may elect to offer alternative benefits for services not otherwise specified as COVERED SERVICES in attachment A. Such benefits shall not exceed the Lifetime Maximum..., and will only be offered in accordance with a written Case Management or alternative treatment plan agreed to by the member, the member's attending physician and the Plan. Case Management services and alternative treatment plans will be ofered to eligible members on a case by case basis to address their unique needs."
Well, I thought that maybe I could get a case manager assigned to help me to get WLS based on all of my comorbid conditons and on the fact that they were now refusing to pay for my regular medical bills because the diagnostic code was "morbid obesity" and they say that the exclusion says that they will not cover any services or supplies relating to obesity, including surgical or other treatment of morbid obesity. Yeah you're reading right, I went to the doctor's last month for swollen glands and chest congestion from bronchitis and during that visit I taked to my doctor about wanting WLS and weight loss attempts, etc. He also thought I had symptoms of sleep apnea so he made a referral for me to have a sleep study done. Well, even though my primary reason for the visit was my swollen glands, he put the diagnostic code as morbid obesity because he was going to help me to prove my case for needing the surgery. Well, the insurance co. is now refusing to pay that bill saying that it is not a covered service in my plan due to the exclusion!?!?!? Can you believe that insanity???? Anyways, I decided to try to get a case manager to help me not only to try to get the surgery approved but also to have them pay for my medical needs from comorbid conditions that are directly related to the morbid obesity. Well, I was told I couldn't have a case manager because of the exclusion on my policy since I wanted the case manager for obesity related concerns?!?!? Well, maybe I am missing something here or reading the explanation of what a case manager is for wrong or something but I thought it sounded like a case manager would help you to get the medical treatment you needed DESPITE exclusions/non-covered services! Is it just me or isn't that what it basically implies??? So, if I am not wrong, how do I go about getting a case manager assigned to me if they won't get past the exclusion to allow me to have one? Ugh...BCBS frustrates me sooooo much! I think I may call them back and try to get a case manager based on my comorbid conditions alone without mentioning the "morbid obesity." Maybe that will work. Who knows?!?!?
My husband called Gary Viscio yesterday about them not wanting to pay my medical bill and Gary told my husband that it sounded like discrimination and I may be able to fight them on it. I am going to call Gary and talk to him more about it and also about the case manager thing. I hope he can help me. I am willing to pay for a lawyer if I have to have one in order to fight this, but I hope I don't have to due to financial limitations. Oh well, what must be done, must be done. I firmly believe in the saying: "Where there's a will, there's a way." Hope that proves to be true in my case. Well, I think I've rambled on long enough for tonight. I will close for now. Thanks for reading.
Until next time,
Tammy
PS -- I forgot to mention that I have been following a low carb diet (kinda my own mix between Adkins and South Beach) for the last 6 weeks (approximately). I feel like I have lost some weight because my clothes are fitting a little better and there is a little more space between my belly and the steering wheel of my car!!! LOL (not really a laughing matter but thought I'd lighten the mood a little). According to my scale, I have lost approximately 20-24 lbs. but I have a feeling that my scale is not the same as the doctor's scale. I think if I had lost that much it be a little more noticeable. I go back to the doctor's next week for my "official" sleep study results and I look forward to weighing on his scale to see what I have actually lost. It would be great if my home scale is accurate and I really have lost 20-24 lbs! I pray it is. But I guess any loss is better than no loss at all huh? I actually feel much better and have more energy since I began the low carb diet (of course the Wellbutrin my doc prescribed at my last visit might also be helping with this too! LOL). I have done low carb dieting before and usually do feel better while doing it. I can just never end up sticking to it for more than 4-6 months. I am really gonna try to stick to it this time because I want to lose as much as I can before surgery (especially since I might never get it at this rate). I also figure that after surgery you have to eat mostly protein anyways and no sugar so I figure if I get used to it now, maybe the head hunger and change of lifestyle won't be as hard. Carbs really do me in and I know I feel better when I don't eat them (bad carbs that is). It also helps with my insulin resistance to not eat bad carbs/sugar. Ok, I am rambling again, sorry. Until next time...
6/18/05 Good news! I weighed myself on a doctor's scale (we have one where I work because I work for a Mental Health Agency) the other day and according to that scale, I have lost 19 lbs!!! Also according to that scale, I now weigh 320 lbs! I am so happy. I have a doctor's appt. scheduled for Tuesday, 6/21/05 and will be able to see how accurate these results are. Last time I was at the doctor's office (5/9/05), I weighed 339.4 lbs. I guess this low carb diet I am on is actually working. I can't complain although I still want to have weight loss surgery. I have lost weight on low carb diets before but I can never seem to stick to them long term and always end up gaining all of the weight back (+ some). It's been hard because I still crave carbs and sweets but I know this is something I need to do. With having PCOS and being insulin resistant, I know I must refrain from eating white flour & starches (bad carbs) and sugar products. Plus I figure eating a low carb diet now and making this way of eating a "lifestyle change," that maybe this will help me (with cravings and head hunger and successful weight loss) once I have the WLS. I already feel so much better since beginning this low carb eating - I have more energy and I am sleeping better for some reason. My clothes are fitting a little better too. Ok, well I need to get to bed so I will end this for now. Thanks for reading.
Until next time,
Tammy
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 320 lbs. Me - Christmas 2004 |
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