Feeling really discouraged

[HereIGoAgain]

Ive shared before but ill briefly explain that I have been having some troubles due to three separate hernias. I was referred to a general surgeon to get the umbilical and abdominal hernias fixed and was supposed to get the hiatal hernia worked on separately. I do not want to have to do two surgeries if it can be avoided so despite the abdominal hernia causing severe pain 1-2 times per week I postponed that surgery. Well today was my endoscopy and with it seems to have gone my hope that I would get to meet with a bariatric surgeon to troubleshoot it as they have decided the hiatal hernia isnt problematic enough to require surgery. In fact the doctors exact words were "you just need to lose weight and eat less". ARRGGHHH!! I already eat very little since my sleeve surgery (but of course they dont care). Anyways I called Dr. Keshishian's office thinking maybe I can get my primary care doctor to refer me to him but his office said that Blue Shield is now considered "Out of Network" for them. I cant self-pay (my student loans are horrendous so taking on another huge loan is out of the question). It is such a shame that we have so limited choices for DS doctors. Why is this?

 

[DSRIGGS]

Ive shared before but ill briefly explain that I have been having some troubles due to three separate hernias. I was referred to a general surgeon to get the umbilical and abdominal hernias fixed and was supposed to get the hiatal hernia worked on separately. I do not want to have to do two surgeries if it can be avoided so despite the abdominal hernia causing severe pain 1-2 times per week I postponed that surgery. Well today was my endoscopy and with it seems to have gone my hope that I would get to meet with a bariatric surgeon to troubleshoot it as they have decided the hiatal hernia isnt problematic enough to require surgery. In fact the doctors exact words were "you just need to lose weight and eat less". ARRGGHHH!! I already eat very little since my sleeve surgery (but of course they dont care). Anyways I called Dr. Keshishian's office thinking maybe I can get my primary care doctor to refer me to him but his office said that Blue Shield is now considered "Out of Network" for them. I cant self-pay (my student loans are horrendous so taking on another huge loan is out of the question). It is such a shame that we have so limited choices for DS doctors. Why is this?

Maybe is just your plan but I will be having my third surgery with Dr K within the next month and I am BCBS PPO. So I am confused. Hopefully you can get this figured out soon. Are you also planning on getting the second phase of the DS?

 

[DianaCox]

November (open enrollment) is coming up - can you change plans?

 

[HereIGoAgain]

November (open enrollment) is coming up - can you change plans?

My husband and I both work in education so neither of us has open enrollment again until May which would take effect in July.

 

[HereIGoAgain]

Maybe is just your plan but I will be having my third surgery with Dr K within the next month and I am BCBS PPO. So I am confused. Hopefully you can get this figured out soon. Are you also planning on getting the second phase of the DS?

I'm thinking it must have to do with being HMO but hopefully it's still not a closed door.

 

[DSRIGGS]

I'm thinking it must have to do with being HMO but hopefully it's still not a closed door.

I hope so as well. Best wishes.

 

[HereIGoAgain]

I hope so as well. Best wishes.

Thank you!

 

[DianaCox]

You are in CA - which DS surgeons are in-network for you? Because if there is no qualified in-network surgeon (keeping in mind your reasonable desire to have ALL of these problems fixed at once), then your insurance almost certainly has to pay for you to go to a qualified out-of-network surgeon.

If your plan is an HMO, even better, because there will NOT be a qualified surgeon in-network, and Larra and I have helped people with this situation before.

What you have to do is to request your PCP to refer you to Keshishian as a covered out-of-network referral, because there is nobody in-network who can deal with your medical situation in one surgery, and you want ONE surgery. S/he will say no, or she will make the request to the HMO managed care for the out-of-network referral, and you will in either case get a denial, vesting your appeal rights.

Then, while we help you appeal the denial, you will self-pay for a consult with Dr.K, who we hope can write you an LOMN that says you need the switch, and that he can also repair your umbilical, abdominal and hiatal hernias at the same time. It is more likely than not that the DMHC will overturn the plan's denial. And you should get reimbursed for the cost of the consult

That's how to handle it from an insurance perspective.

However, depending on how much of a problem the abdominal and umbilical hernias are, I would like to point out another set of considerations.

• You are still MO, I assume.
• If you get the abdominal and umbilical hernias fixed NOW, you are not going to have as good a cosmetic result as you would if you could wait until after you lose more weight after getting the switch.
• In fact, if you can wait, it is possible that you could get them fixed AND get a proper abdominoplasty covered by insurance (again with help from me and Larra - I got my husband an abdominoplasty to avoid the use of mesh to repair his umbilical hernia, and he got a bit of a FUPA lift as a bonus).
• Similarly, it is possible that your surgeon is right and that you might not need a hiatal hernia repair after you lose more weight - and a hiatal hernia repair after having a sleeve is more difficult, because there is no fundus to make the Nissen fundoplication wrap (@Larra, do I have that right?). But that is something to ask Dr.K.

 

[HereIGoAgain]

Thank you for this Diana. The primary reason for my disappointment today was with them saying I don't need surgery for the hiatal hernia they are not giving me a referral to the bariatric surgeon and I already have a referral to the general surgeon for the other hernia repairs. That sort of steals my excuse to my primary doctor to ask for a referral to Dr K on the grounds that he is the only one qualified right? I'm worried that if I say I need to talk to him to discuss revision to DS he would have justifiable reasons to deny me based on my BMI so it seems I have to ask in a way that ties in my hernias. Any thoughts if I can't include the hiatal hernia as part of my request?

 

[DianaCox]

What is your BMI?

 

[Larra]

@DianaCox got the explanation about the Nissen fundoplication not being possible after a sleeve right. Setting that aside, many people with a small hiatal hernia really don't need surgery to fix it. Surgery is the last resort for that type of hernia, and for someone who is overweight, losing weight often does help. However, my guess is that, if Dr. K were in there revising your sleeve to a DS and he saw the hernia, he might do something less than a fundoplication to help it along, like just tighten up the opening in the diaphragm where the esophagus comes through. Is that necessary for you? I have no way of knowing.
In any event, I think Diana has given you good advice about how things work with insurance if you have no in-network qualified surgeon for the procedure that is medically necessary, meaning the DS. It's important to get the denial before you do anything else, and I will leave further advice on this up to her. Once you have the denial, we can help from there. There are never any guarantees but you have nothing to lose by appealing.

 

[DianaCox]

And get a copy of your Evidence of Coverage document (about 100 pages, NOT just the summary of benefits - you want the DETAILED contract) so we can review your particular contractual rights and route of appeal. Some governmental agencies are self-funded, which means they DON'T have to comply with the CA Knox-Keene Act, and have their own peculiar appeal rules, so we need to see the EoC.

 

[HereIGoAgain]

What is your BMI?

37.7

 

[DSRIGGS]

FYI - Dr K just posted this video on his FB page, and it just happens to be a laproscopic hiatal hernia repair for a patient who already had a sleeve gastrectomy. He is the man!

 

[MegMac86]

Ive shared before but ill briefly explain that I have been having some troubles due to three separate hernias. I was referred to a general surgeon to get the umbilical and abdominal hernias fixed and was supposed to get the hiatal hernia worked on separately. I do not want to have to do two surgeries if it can be avoided so despite the abdominal hernia causing severe pain 1-2 times per week I postponed that surgery. Well today was my endoscopy and with it seems to have gone my hope that I would get to meet with a bariatric surgeon to troubleshoot it as they have decided the hiatal hernia isnt problematic enough to require surgery. In fact the doctors exact words were "you just need to lose weight and eat less". ARRGGHHH!! I already eat very little since my sleeve surgery (but of course they dont care). Anyways I called Dr. Keshishian's office thinking maybe I can get my primary care doctor to refer me to him but his office said that Blue Shield is now considered "Out of Network" for them. I cant self-pay (my student loans are horrendous so taking on another huge loan is out of the question). It is such a shame that we have so limited choices for DS doctors. Why is this?

I hate medical insurance rules so much!!! Best of luck as you navigate the maze. ❤️