Current Status of Insurance Approval

Well, I can't be approved if I haven't submitted yet. I just wanted to make a quick post as to where I'm at in this insurance approval game.

Before my bariatric program will submit to my insurance I had a To-Do List:

9 month doctor supervised diet
Pre-Qualifying blood work, EKG, X-Ray
Psychological Evaluation
Binge Eating Group

As you can see I only have one more thing on my list, and only 3 more months of the diet left to go! Then they will submit all of my stuff to the insurance. If I'm lucky it will only take a few weeks for them to approve it. I'm getting anxious!

The Mental Preparation

When I first found out that I had to complete a 9 month supervised diet I wanted to throw in the towel. I had already decided what surgery to get...done all my research...been fat for WAY too long - I  was ready to have this surgery NOW!

BUT - this 9 month wait has been a blessing in disguise. It's given me time to educate myself more and prepare myself mentally. It has actually gone pretty fast and I only have 3 more months left of it.

Which leads me to AH-HA #2: Preparation
We all know that WLS is only a tool...not an answer. But, I have to be honest,when I first made the decision to start the required 9 month diet for surgery I didn't really want to think about lifestyle changes. I just figured I would stuff my face and exercise when I felt like it (which was rare) and it wouldn't matter if I lost or gained any weight before the surgery, because the surgery would take care of it for me. I was also counting on the surgery to change a lot of other things too:

"When I have surgery I won't have any cravings, so I won't worry about them now."
UMM....NOPE! According to most post-op surgery folks they say they have to overcome a lot of "mental hunger/mental cravings" after surgery. Most cravings are mental, and often a response to an emotion we are feeling (even if we don't realize it). That's why I've been recently working on distracting myself when I get a craving...I got that from my Binge Eating Group. First, when I have a craving (or "think" I'm hungry) I have to wait 10 minutes to see if the craving/hunger is still there. I have to evaulate when I last ate to determine if I'm actually hungry or if it's a mental hunger. During those 10 min I find something else to keep my mind occupied (brush teeth, do some stretches, change rooms or activities, etc). Most of the time it works for me. In the beginning it was hard. First few days I gave into the craving. Next few days I would give into the craving, but replace the junk food with a healthy one. I usually crave sweets, so instead of going for cookies or sweet cereal I would grab a piece of fruit. After about 2 weeks I found I was craving things less and less. Maybe due to awareness? Maybe due to avoiding trigger foods? Maybe a combination of both.
(Side Note: my psychologist required me to attend 4 weekly sessions of a Binge Eating Support Group. When she told me that I thought to myself, "Right...like that is really going to benefit me." It has really helped me to be more concientious and gave me coping strategies)

"When I have surgery all of my old eating habits will just go away."
AGAIN...NOPE! I'm an emotional eater and a habitual eater. Meaning I eat when I'm down or upset...for comfort, and I eat out of habit - even if I'm not hungry. My worst habit is eating at night...around 8pm. It's my unwind time in front of the TV. It's like whenver I sit in front of the TV I feel like I need to have something to eat. Most of the time I'm not really even hungry...it's just this habit...this behavior of TV and food going hand-in-hand. This has been a hard one for me to break. I have good and bad days. Right now I'm just trying to focus on eating a healthy, portion-controlled snack...as I wean myself off of this behavior.
As far as the emotional eating, I'm also working on that. One coping strategy (learned in my Binge Group) is relaxation. When I'm emotional I sometimes don't think clearly...and I sometimes prefer not to think at all, which is why I end up eating until I'm so uncomfortably stuffed. By practicing my relaxation techniques it really clears my mind. It's kind of like a "restart" button when your mind is just overloaded. It works REALLY well when I do it. The part I'm having to learn is recognizing when I need to step back and take a chill pill before I self-medicate with food. It's a work in progress.

"When I have my surgery exercise will be so much easier."
Well, YES and NO. Yes, it will be easier on the body because I won't be carrying around all of that weight. But, I don't think getting into the habit of exercise will be much easier than now. Why not try and get into the habit NOW?  Right now I'm trying these walking dvd's at home. They are perfect, because I get moving, but they aren't so hard that I never want to do them again.

Anyway, I've come to realize that if I truly want to be successful in using my WLS tool, then I need to prepare myself NOW and not count on the surgery to take care of it all for me. I'm glad I've had 9 months to figure this out and prepare myself. I'm glad I have a really good bariatric program that provides me with the tools to succeed after WLS.

My Hospital, My Bariatric Program, My Surgeon

I live within driving distance of the Cleveland Clinic...the #4 hospital in the country. It's about an hour drive for me to get there. I have some good hospitals that offer good bariatric programs within my own city, but they all had program fees (above and beyond what the insurance covers) and I just couldn't afford it. I had heard so many great things about the Cleveland Clinic in general I decided to check them out as well.

Which brings me to AH-HA #1:
DO YOUR HOMEWORK. After you've researched and made your decision on what WLS procedure is best for you...don't forget to research surgeons and hospitals. Some people may be limited to what is in their area if they don't live in or near a larger metropolitan area. However, if you live in or near a larger city check out all of your options. There are three major hospitals that offer bariatric programs within my own city. I called each one and asked for all the basics: FEES, REQUIREMENTS, SURGEONS, INSURANCE. Most of them also had websites that already had answers to these questions. Once I gathered that information I was a little discouraged...they all had program fees ranging from $800-$1900. OUCH! So, I decided widen my search area and I came across the Cleveland Clinic. NO PROGRAM FEES! GREAT BARIATRIC PROGRAM! GOOD PATIENT FEEDBACK ON SURGEONS!

My Hospital: Cleveland Clinic.It has the Bariatric and Metobolic Institute that has a very thorough bariatric surgery program. This is how My Bariatric ProgramWorks:

1)You call and they pre-screen you by asking for your insurance information, height and weight, medical conditions (co-morbidities) and tell you if you qualify for WLS. If you qualify they send you a Patient Worksheet Questionnaire.

2) Once you send in the Questionnaire they review your medical history and make sure you are pre-authorized with your insurance for any pre-op testing and appointments.

3) If everything is kosher with your insurance they schedule you for the required WLS workshop

4) The WLS workshop is about 3 hours long. They encourage you to bring an immediate family member or support person so that they can learn with you. The workshop covers  all of the different types of sugeries; all of the pre-op preparation, life after surgery, and the expected lifestyle changes that come with each of the surgeries. It's VERY thorough. At this point they also assign you your surgeon and clinic ID.

5) After completing the WLS workshop you make appointments for your pre-op testing. These test can vary based on your health situation, but some of the basics that most patients will go through are
    - Bloodwork
    - EKG (to make sure your heart is stable for surgery)
    - X-Ray (to make sure your lungs are healthy enough for surgery)
    - Psychology (to identify and work through and mental/emotional issues that might prevent you from being
successful after your surgery)
    - Nutrition (to make sure you meet your insurance diet requirments, prepare you for the pre-op diet, and educate you on the new eating habits after surgery)
    - Meet your surgeon
They do their best to schedule these appointments in one day so that you don't have to keep coming back for each appointment.

6) Once all of these things are complete and you met all of your insurance requirements they submit all of your information to your insurance for approval.

7) Once approved they schedule your surgery and you come in for a Pre-Op clinic visit, which includes a consultation with your surgeon.

8) After surgery there are multiple follow-up appointments and support groups.

My Surgeon is Dr. Matthew Kroh. I've only met him once thus far, and it was very brief. He seems like a nice man. I know I will be meeting him again for a more in-depth consultation once my surgery is scheduled. I think I will get a better feel for him at that point.

Insurance

As I said in my Beginning  post my new insurance covers WLS...sort-of.

I have CareSource - Ohio. They only cover certain WLS procedures (Roux-en-Y and LapBand) and only on a case-by-case basis. When I first contacted them to see if they covered it the customer service rep said NO. Then someone (on the Obesity Help website) suggested that  I call again with the procedure code for Roux-en-Y (CPT code: 43645 - Roux-en-Y Gastric Bypass). When I did that they told me it's not usually a covered procedure unless it is deemed "medically necessary" by my primary care physician, and that I meet certain "requirements" for approval.

What are those requirements?

-9 month doctor supervised weight loss program (completed within the past 5 yrs). The doctor must document weight, dietary plan, exercise plan and progress on a monthly basis.
-Documentation of at least one obesity related co-morbid condition (diabetes, high blood pressure, high cholesterol, heart disease, sleep apnea, etc)
-BMI of 40+

•My BMI is over 50 - CHECK
•I have Diabetes, high blood pressure, sleep apnea - CHECK
•9 month doctor supervised weight loss program:

Right now I'm in month SIX...so only THREE more months to go! I know I shouldn't be too excited right now, because I'm not approved yet. However, I'm going through a program at the Bariatric and Metobolic Institute at the Cleveland Clinic and they are almost sure I will be approved.

The first six months of my "diet" (beginning Sept 2009) I started with my PCP and told her about my decision to have gastric bypass surgery. I told her all the information that needed to be documented and that she would need to write a recommendation letter. She agreed to work with me and also counseled me about the surgery (the pros and cons).

During the same time I had also signed up for the bariatric program thru the Cleveland Clinic. In November I went to a seminar and got registered with them and made all of my pre-op appointments. They handle all the insurance stuff and won't make appointments with-out pre-authorization from your insurance company. I double checked on this. Every appointment the clinic made I called their "insurance specialist" to confirm my insurance had authorized it...and every time (so far) it has. I haven't received a single bill. I will be continuing the last 3 months of my diet with the Nutritionist in their Bariatric Program.

Here's to hoping for approval!

The Beginning

I think the first time I heard about weight loss surgery (WLS) was around 2003...I was around 23...and weighed about 265 lbs. I had a co-worker that had heard about it and was considering it, but didn't know much about it. So we did a little internet research to find out more and it kind of freaked us out.
The first thing we came across was before and after pictures of people who had Roux-en-Y. They were very dramatic and graphic...with loose skin hanging all over the place...it looked like these people were buried in their skin. Then we read about what the surgery involved and all the risks and came across a few bad stories. That was enough to make my friend think twice.

From that point on, WLS was always a distant thought in my mind. My first thoughts were, "I would like to lose weight, but WLS is too extreme...what if I end up looking like a pile of skin?" I figured I would have to lose weight without surgery, so over the next few years I tried many diets. Diets I had already tried before...Slim Fast, Dexitrim, Atkins, South Beach, Weight Watchers, Low-Calorie...you name it. I found I lost the most weight with Atkins and Weight Watchers, so I would lose anywhere from 25-50 pounds...only to gain it back and then return to one of the two diets because I knew I could always get some sort of results.

Then I started hearing about famous actors/actresses having WLS, and it peaked my interest again. If these people were having it and they didn't look like a pile of skin then maybe I should research some more. In 2008, after spending several months researching I had decided to have the Lap Band procedure. I felt it was less extreme and more easily reversible...not to mention it was also much more affordable than Roux-en-Y. I had my money all ready, my surgery scheduled in Mexico...I was ready to go. Unfortunately, some unexpected events occurred that required me to use my surgery money. I was so disappointed, and had decided that I should just accept the fact that I will have to live the rest of my life as a fat ass!

So, if I was going to be fat for the rest of my life I might as well "enjoy" the only "fun" thing about being fat: eating whatever I wanted and not caring about it. Accept deep down I did care. I felt disgusting and fat and out of control and hopeless. That is when I peaked at my highest lifetime weight: 335 pounds! That is also when I was diagnosed with Type II Diabetes, Hypertension and eventually sleep apnea...all at the age of 29! It was all so overwhelming and depressing. I had to be a little more conscious of what I ate and began to lose weight…about 25 pounds.

And then in 2009 we moved to another state, and I got new insurance…and guess what? They cover WLS (with a catch – that’s for another post)!

I still wanted the Lap Band procedure, but a friend on the Obesity Help website recommended researching Roux-en-Y and a few other WLS surgeries before deciding. I’m so glad I did, because I decided to get the Roux-en-Y procedure. After talking to my Primary Care Physician (PCP) and looking into all the different type of WLS surgeries, and then attending a seminar on them I feel confident that the Roux-en-Y procedure will be the best tool for me! I can’t wait!