The long wait......

nedsmehlp

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Aug 10, 2016
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I just went to my family Dr Tuesday to start my 6 month diet. Had to go to the dietician on Thursday. Have a pulmonary Dr scheduled Sept. 13th and cardiologist same day. Already saw the Psychologist. Talked to the Dr office that will do my DS and was told my insurance company won't pay for a consult until after the 6 months. So she said it will be a good month and a half to two months after that before I can get scheduled for surgery. That means 71/2 to 8 months from now. That seems so long!! I asked about self pay on the consult before that, but she didn't encourage that. I have a question.....if I lose weight (20 lbs or more) will they say I don't need the surgery since I have lost on my own? I think I can lose 20 lbs or more in 6 months, but as usual I would just gain it back with more weight in time. Also I have seen people post about constipation, and thought with malabsorption you had the opposite? These may be silly questions, but I know I'll have a hundred more within the 8 months.

Thanks for any help.
 
My insurance required me to lose 10% of my body weight before approving me. I thought, and still do, that such a requirement was total bullshit. I lost it and was approved. I was very open about my WLS and several people I worked with came to me for advice. Most of them did not follow through because they didn't lose the weight. In my opinion, this is an artificial and totally unnecessary requirement designed to make people quit seeking WLS. Sadly, some people did. Most of the requirements are designed to make a person quit. If you want it bad enough, complain about the silliness here. (We won't judge.) Then dig in and meet those silly things and get your surgery.

As for the constipation, I did suffer from severe constipation for about 6 months. My doctor did a stool analysis. I changed to a different pro-biotic, ate some yogurt daily, and no more problems.

As for the wait, I was denied. I gained more weight and a few more co-morbid conditions. Then 3 years later, I was approved. I thought I could do it on my own after the denial. I was wrong. While I was pissed at the time, it worked out for me. I would have gotten a RNY. That would not be a good fit for me.

Your questions are not silly.:D
 
Yeah, the hoops are designed by insurance companies to make you give up. Hang in there...the time will pass before you know it and your date will be here.

And yeah, most of us deal with constipation not diarrhea. HOWEVER, in the first month before getting all your vitamins on board and while your insides are still very swollen and pissy, diarrhea may be more normal. I know I had the runs the first two weeks but once on solid foods, that resolved VERY fast.
 
1) You can start the 6 mo diet, and challenge it at the same time:
http://asmbs.org/wp/uploads/2011/03/PreopWtLossRequirements-May2011.pdf
ASMBS Position Statement on Preoperative Supervised Weight Loss Requirements

Summary and recommendations

First, no class I studies or evidence-based reports has documented the benefits of, or the need for, a 6 –12- month preoperative dietary weight loss program before bariatric surgery. The current evidence supporting preoperative weight loss involves physician-mandated weight loss to improve surgical risk or to evaluate patient adherence. Although many believe benefits could result from acute preoperative weight loss in the weeks before bariatric surgery, the available class II–IV data regarding acute weight loss before bariatric surgery are indeterminate and provide conflicting results, leading to no clear consensus at this time. The preoperative weight loss recommended by the surgeon and/or the multidisciplinary bariatric treatment team because of an individual patient’s needs might have value for the purposes of improving surgical risk or evaluating patient adherence. However, it is supported only by low-level evidence in the published data at present.

One effect of mandated preoperative weight management before bariatric surgery is the attrition of patients from bariatric surgery programs. This barrier to care is likely related to patient inconvenience, frustration, healthcare costs, and the lost income resulting from the requirement for repeated physician visits not covered by health insurance.

It is the position of the American Society for Metabolic and Bariatric Surgery that the requirement for documentation of prolonged preoperative diet efforts before health insurance carrier approval of bariatric surgery services is inappropriate, capricious, and counterproductive, given the complete absence of a reasonable level of medical evidence to support this practice. Policies such as these that delay, impede, or otherwise interfere with life-saving and cost-effective treatment, which has been proved to be true for bariatric surgery to treat morbid obesity, are unacceptable without supporting evidence. Individual surgeons and programs should be free to recommend preoperative weight loss according to the specific needs and circumstances of the patient.​

2) Are you seriously ill from your morbid obesity? Diabetic? High blood pressure? Can you assert that the longer it takes to get your morbid obesity under control, the higher your risk of death or disability from this unnecessary diet?

3) Can you assert that you have dieted numerous times in the past with the same, predictable results, which was temporary lost, followed by regain?

4) Do the diet, and try to get it waived at the same time.
 
@nedsmehlp , I know it's frustrating, but try to jump through those hoops because it'll be worth it in the end. Like you, I'm starting my process and seeing my surgeon for the first time next month. We can do this!

Still, maybe you *can* get it waived like Diana mentions. Fingers crossed!
 
If you try to get it waived, while doing it, at least you might shorten the time if they do waive it. If they don't, you won't have wasted time fighting it.

The insurance company won't penalize you for losing some weight on the diet - your starting weight is what counts. But you don't need to kill yourself on the diet either.
 
If you try to get it waived, while doing it, at least you might shorten the time if they do waive it. If they don't, you won't have wasted time fighting it.

The insurance company won't penalize you for losing some weight on the diet - your starting weight is what counts. But you don't need to kill yourself on the diet either.

I want to add my thanks on to you for mentioning that she might fight the diet. I've started my diet because the surgeon's office said my insurance may require a 9 month one. At first the idea didn't bother me because it would take me to next May when my classes are out. BUT if I can get it waived or shortened, perhaps I could have it done over my Christmas break from school. Like you said, it doesn't hurt to try WHILE I'm doing the diet anyway.

So, thanks!
 
@Butterfly I'm in the exact same position. I just started my "required" 6 month diet and felt okay about it because it would put my surgery sometime into May or June when I am not teaching FT. I didn't even consider the idea of fighting to get the diet requirement shortened as @DianaCox mentioned. But I am dealing with horrible mobility issues due to chronic tendinitis in my left foot that has led to a permanent handicapped placard so I can get around the campus where I teach better. Every step at this weight is painful and miserable. My surgeon thinks it's likely I have sleep apnea since I have like three of the indicators. My biggest fear is not surviving due to some collapse in health before my surgery date. My insurance (the State Employee version of BCBS of TN) used to require that state employees go on the diet and FAIL. On the non-state employee version of the same plan they were requiring the archaic "lose 10% of your body weight" as a mandatory qualifier. My surgeon's office says that the requirement that I fail the diet is not thing any longer. I would like to have the requirement that I spend 6 months on a diet that probably won't do anything for me to be MY decision and not the insurer's. It's so frustrating. I suppose I could do this over my Christmas break if I got it waved and my surgeon had an opening, but I'm probably going to be stuck waiting till after the Spring semester. Waiting 9 months while every step I take causes me agony and while jumping through the hoops. I just hope they don't try to deny me for whatever reason.
 
@writegirl, get a copy of your policy to make sure you meet all their criteria (no matter how ridiculous) and have all your i's dotted and t's crossed when you finish the 6 months thing and request approval. Make it as hard as possible for the insurer to find an excuse for a denial, because based on what we've seen over the years, even the slightest excuse will be used.
and, given that you are really struggling with your mobility and possibly other problems, trying to get that idiotic requirement waived is not a bad idea. You have nothing to lose by trying, and if you could get your surgery a few months sooner you will be on your way to better health and less pain that much sooner.
 
@Butterfly I'm in the exact same position. I just started my "required" 6 month diet and felt okay about it because it would put my surgery sometime into May or June when I am not teaching FT. I didn't even consider the idea of fighting to get the diet requirement shortened as @DianaCox mentioned. But I am dealing with horrible mobility issues due to chronic tendinitis in my left foot that has led to a permanent handicapped placard so I can get around the campus where I teach better. Every step at this weight is painful and miserable. My surgeon thinks it's likely I have sleep apnea since I have like three of the indicators. My biggest fear is not surviving due to some collapse in health before my surgery date. My insurance (the State Employee version of BCBS of TN) used to require that state employees go on the diet and FAIL. On the non-state employee version of the same plan they were requiring the archaic "lose 10% of your body weight" as a mandatory qualifier. My surgeon's office says that the requirement that I fail the diet is not thing any longer. I would like to have the requirement that I spend 6 months on a diet that probably won't do anything for me to be MY decision and not the insurer's. It's so frustrating. I suppose I could do this over my Christmas break if I got it waved and my surgeon had an opening, but I'm probably going to be stuck waiting till after the Spring semester. Waiting 9 months while every step I take causes me agony and while jumping through the hoops. I just hope they don't try to deny me for whatever reason.
You should be appealing the diet thing too. And get the surgery ASAP. Teaching or not!
 
I know work gets in the way, but if you can take Family and Medical Leave, I would just get the surgery done. My guess is your job has short term disability or your state. In California, the state does it.
 
By the way, for those who can afford it - if you submit a request for preauthorization, and are denied, your appeal rights have vested, and you can go ahead and self-pay and have your surgery while you are appealing. You of course risk losing the case and ending up out the money, but if you can afford the possibility of paying in advance and losing, you don't HAVE to wait. Whether or not you would win a case against the insurance company arguing that their 6 or 9 month pre-op diet policy is inappropriate as being medically unsupported, I cannot say. The external medical reviewers usually take each case on its own merits, so if in YOUR case, waiting is likely to put your life at risk, or cause you permanent harm, you have a better argument. The ASMBS statement does not overrule the insurance companies' policies, unfortunately, though it DOES apply pressure on a case-by-case basis, and if you ended up having a heart attack or stroke while waiting through appeals of a medically unsupported policy that runs contrary to the position statement of the ASMBS, I think you could win a case against your insurance company for bad faith denial.

The problem, however, is that for some reason that makes no sense to me, insurance companies are allowed to exclude coverage for bariatric surgery AT ALL - so winning a claim against the insurance company that says they will cover it, but only if you meet ridiculous and medically-inappropriate requirements, is hard to do.

~~~~~
Parking this here so I can find it again - I found it while researching something for this post (it is California-centric but summarizes what is needed every time someone comes here for insurance help):
http://www.scottglovsky.com/how-to-...rance-claim-treatment-or-procedure-is-denied/

And this, while I'm at it: http://www.mvplaw.com/post/articles/bad faith.pdf
 

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