HeatherG

BCBS Approval

21 posts in this topic

I have been trying to have the Gastric Sleeve since September 2016. I lost weight in 2015, From February to August. I lost 50 pounds, kept it off until around July 2016. I started my application in September and have gained all my weight back since. The lady that I have been talking to keeps telling me that insurance needs me to see my PCP again every time I talk to her. I have been seeing my PCP for almost 2 years, every month. I have recently been diagnosed with fibromyalgia. Does it usually take this long to get the paperwork together and have ins approve the surgery? I don't want to keep pestering her about it, but I am starting to get impatient. Now my OB/GYN is talking about doing a hysterectomy too, but I want to have the sleeve done first. Do I continue to stay on the doctor's office or just wait to see what happens? I need to be able to schedule my hyst but I cant until I get this sleeve scheduled first.

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I would call and talk to your insurance to see what is actually required.

my BCBS required a 6 month "supervised" diet as one of the things.  I had to do a weigh in once a month for 6 months.  Could this be what they are doing!  Some insurances require other testing.  

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call them & get them to send it to you in writing. bcbs told me I didn't a 6 month diet 3 to 5 times, then when I got

everything else done I needed the 6 month diet.

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BCBS of texas need 

3 classes, ( I did them all in one day )

An evaluation

1 Nutrition class

3 years of past weight history

Recommendation note from my Primary care doctor 

 

I would call your insurance to ask them for what all you need.

Originally my doc office told me I needed 6 classes, and could only do One a month, but that was not the case. 

Good Luck! 

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Insurance (BCBS Texas ANTHEM) came back in two days and said that I needed to complete 6 months of diet monitored by a doctor or dietician, a psych evaluation and that's it.

Is this considered a pre-approval?

And if so...6 months? How is the fact that I have been on a diet since I was 12 and am now 41 not enough? What should I think now? What is there to expect? I have an appointment with my gp tomorrow morning to see if she will back me at all since I just dished out $400 on Qsymia in March and April (which did absolutely nothing) and have kept a food journal for the last year almost daily.

Can you get around that requirement? Why would they do that? Is a BMI of 43 not enough?

Please lemme know your thoughts! I sure wish I had your requirements! 

Brandi

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3 hours ago, Phoenix97 said:

Insurance (BCBS Texas ANTHEM) came back in two days and said that I needed to complete 6 months of diet monitored by a doctor or dietician, a psych evaluation and that's it.

Is this considered a pre-approval?

And if so...6 months? How is the fact that I have been on a diet since I was 12 and am now 41 not enough? What should I think now? What is there to expect? I have an appointment with my gp tomorrow morning to see if she will back me at all since I just dished out $400 on Qsymia in March and April (which did absolutely nothing) and have kept a food journal for the last year almost daily.

Can you get around that requirement? Why would they do that? Is a BMI of 43 not enough?

Please lemme know your thoughts! I sure wish I had your requirements! 

Brandi

My BCBS requirements are nearly the same. 6 months of supervised diet w/ monthly weight, psych evaluation, nutritionist appointment, letter from PCP. 

This is not a pre-approval. When you have met all the requirements, your surgeon's office will then submit your packet, and the insurance company has 14 days to either approve it or deny it.

There's no real "getting around" the 6 month part, unless you already have a previous Dr visit where you were weighed. You have to have 6 of them consecutively. 

As far as what you should expect, that's really up to your program/ surgeon. Some are more lax, some are stricter. My surgeon is out of state, so we have a monthly telephone appointment where I report my weight to her and we talk about how I'm doing on the special diet she put me on on month 1. 

I pretty much felt the EXACT same way as you when I found out I had a 6-month wait ahead of me. But honestly, it has been a blessing. My Dr has required me to be on a very low-carb diet, only lean meats and veggies, no dairy. Mostly because the liver has to be flipped out of the way during the Gastric Bypass procedure and she wants it as small as possible.

But just read through this forum a bit and you will see lots of talk about head hunger, if you're not familiar with the concept already. I'm almost 5 months into my 6 month period, and it wasn't really until the 3rd month or so that I really got a grip on head hunger. On being able to stop and say "no, my belly is content, I'm not going to eat xxxxx, regardless of how low carb it is". As well, I have pretty much detoxed from sugar now, and no longer crave sweet things. My kids eat fresh donuts in front of me and it doesn't phase me.

So I said that to say, I would have hated to have been dealing with those issues AFTER surgery. I feel like I am going to be better prepared on the other side.

But maybe you are issue-free, in which case, you'll just have to bear it. But otherwise, it's an excellent time to evaluate your food issues, what your food addictions are, triggers, etc., and come out the other side much better equipped for successful weight loss. Because your sleeve will only be a tool-- if you don't change your eating habits, the sleeve will not help you.

Sorry if I wrote too much, but best wishes to you my friend!

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the best thing I think you can do is call your ins. company & have them send you the requirements in writing.

I went through all the supposedly requirements with bcbs telling me there was no 6 month diet requirements,

then when surgeon filed they told me about it & said they were sorry if they miss led me. now the back page of my insurance

policy has a list of things not covered & weight loss surgery is 1 of them.  

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Posted (edited)

Ditto everything Michael said. I was able to "get around" the 6 month diet requirement because I had previously seen my PCP for phentermine and had a record of him weighing me in every month.  So, if you have something like that, you might be able to expedite the process.  The silver lining of having to do a 6 month diet is that it gives you time to get mentally ready for surgery and start creating habits & routines that will be helpful in your post-op life.  Good luck with everything!

Edited by athenarose
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Thank you so much for your comments! OMG Michael!!!!!!!!!!! Thank you - gave me a lot of information. I am sorry it took me so long to respond. I had a HUGE response then my phone reloaded the page and boop - gone!  I had my dietitian visit yesterday. And you guys are SO right. I am nowhere near ready. I do not understand portions I have NO idea what kind of and how much protein to eat.  I would regain the weight back because ALL of my eating is HEAD HUNGER!!!  

My head hunger and portion control is my problem. Shoot - in this 6 months if I can get control of that, I may not even need the surgery. I NEVER eat when I am hungry. EVER. I never get a chance to GET hungry.  I am going to lurk around on this forum and find the area that talks about head hunger and see what input I can get. I cannot find a trigger at all. It is almost as if it is a fleeting, yet very demanding  - GO EAT- and then - bo, bip,  boop, I toddle off to the break room at work or kitchen at home - mindlessly-  with 500+ calories in the form of a "protein" (in reality CANDY) bar and some package of overly salted (mmmm...salt) nuts. "Healthy" snacks in the break room. Yeah, right.   I just threw out all of the impulse foods at home. Last night when my first GO EAT hit - I was PISSED. Hahahaha!!!

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1 hour ago, Phoenix97 said:

Thank you so much for your comments! OMG Michael!!!!!!!!!!! Thank you - gave me a lot of information. I am sorry it took me so long to respond. I had a HUGE response then my phone reloaded the page and boop - gone!  I had my dietitian visit yesterday. And you guys are SO right. I am nowhere near ready. I do not understand portions I have NO idea what kind of and how much protein to eat.  I would regain the weight back because ALL of my eating is HEAD HUNGER!!!  

My head hunger and portion control is my problem. Shoot - in this 6 months if I can get control of that, I may not even need the surgery. I NEVER eat when I am hungry. EVER. I never get a chance to GET hungry.  I am going to lurk around on this forum and find the area that talks about head hunger and see what input I can get. I cannot find a trigger at all. It is almost as if it is a fleeting, yet very demanding  - GO EAT- and then - bo, bip,  boop, I toddle off to the break room at work or kitchen at home - mindlessly-  with 500+ calories in the form of a "protein" (in reality CANDY) bar and some package of overly salted (mmmm...salt) nuts. "Healthy" snacks in the break room. Yeah, right.   I just threw out all of the impulse foods at home. Last night when my first GO EAT hit - I was PISSED. Hahahaha!!!

Take it a day at a time, and a step at a time. We as humans can only absorb so much drastic change at once. Our brains simply can't focus on too many changes, so take the first week and make a change or two, then on the second week add something else, etc. Many dieters fail because they drastically change their eating patterns overnight, and we simply don't do well coping with that much change at once, and therefore the change doesn't last long.

The excellent advice I received here early out, was to get a food scale and begin to measure your food. It's OK at this point if you're still eating a pound of food or whatever, but at least you will clearly see what a 3oz portion looks like, and that you ate 4 of those portions. 

Replace your need to snack on candy for the time being with Quest protein bars. They are very low-carb, and high protein. There are tons of tasty flavors.

As far as what to eat, generally we aim for a low carb diet. Meat, eggs, veggies, a small amount of dairy. It may seem restricting at first glance, but there is SO MUCH that can be done on low carb. Get on Facebook and look up Low Carbing Among Friends, and Low Carb Hit Parade. Your surgeon or NUT may have specific guidelines though, so check that first. 

As far as head hunger goes, it's what you've already said above- the compulsion to eat, when there is no physical need to do so. It just takes time to work on.  If you can get this settled during this pre-op period, you will see as you read through the forum of other people's successes, and failures, that dealing or not dealing with the head issues will either set you up for good success post-op, or, leave you in the exact same food relationship that you're in now. And no surgery can fix that. 

Please keep in touch with how you're doing!

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@Michael_A, have you tried Oh Yeah! ONE bars? Holy moly! The maple donut, lemon cake, and almond bliss are amazing. Maybe dangerously good. Oh how I miss them while I'm on all liquids. 

Here's a hilarious review of every flavor with pictures:

http://junkbanter.com/2016/01/14/review-ohyeah-one-bars-all-of-them/

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34 minutes ago, Gretta said:

@Michael_A, have you tried Oh Yeah! ONE bars? Holy moly! The maple donut, lemon cake, and almond bliss are amazing. Maybe dangerously good. Oh how I miss them while I'm on all liquids. 

Here's a hilarious review of every flavor with pictures:

http://junkbanter.com/2016/01/14/review-ohyeah-one-bars-all-of-them/

Ooh I might have to look into those. I need something for afternoons at work. As good as reviews for Quest were, I couldnt stand them. That review is hilarious!

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15 minutes ago, delilas said:

Ooh I might have to look into those. I need something for afternoons at work. As good as reviews for Quest were, I couldnt stand them. That review is hilarious!

Try them! You won't regret it. 

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I'm pretty meh about Quest except Cinnamon Roll, but Oh Yeah Almond Bliss is good. Must try the others...

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On 5/31/2017 at 11:17 PM, Phoenix97 said:

Insurance (BCBS Texas ANTHEM) came back in two days and said that I needed to complete 6 months of diet monitored by a doctor or dietician, a psych evaluation and that's it.

Is this considered a pre-approval?

And if so...6 months? How is the fact that I have been on a diet since I was 12 and am now 41 not enough? What should I think now? What is there to expect? I have an appointment with my gp tomorrow morning to see if she will back me at all since I just dished out $400 on Qsymia in March and April (which did absolutely nothing) and have kept a food journal for the last year almost daily.

Can you get around that requirement? Why would they do that? Is a BMI of 43 not enough?

Please lemme know your thoughts! I sure wish I had your requirements! 

Brandi

@Phoenix97 - If you have records from your food journal with weights every day or week or something... Plot them out on a graph and bring those in to your MDs and have those submitted as part of your evidence of a supervised diet trial. If you met your doc once a month and reported your progress you should be able to honestly state this was monitored. 

It seems all the plans everywhere have some requirement about this. In a different thread I posted that I think I was just dead stupid lucky to be a geek - I walked into my psych evaluation with a graph of my weights, calorie intakes, and amount of exercise. I had tried 4 times in 2016 to exercise hard, eat less... which I did... and it led to no weight loss, zero nada nil zilch. My body just commensurately went into starvation mode. 

More to the honest point of your comment, having been on a diet since you were 12 and now are 41.... This is all sort of stupid, since for 99+% of people diet fail, and the only PROVEN method for weight loss is WLS. 

Maybe we should all become approval people for the insurance companies after WLS....

 

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9 hours ago, Gretta said:

@Michael_A, have you tried Oh Yeah! ONE bars? Holy moly! The maple donut, lemon cake, and almond bliss are amazing. Maybe dangerously good. Oh how I miss them while I'm on all liquids. 

Here's a hilarious review of every flavor with pictures:

http://junkbanter.com/2016/01/14/review-ohyeah-one-bars-all-of-them/

OOoohhh  :-)    I saw them at GNC the other day but had no idea what they were. I will have to try one!!

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4 minutes ago, Michael_A said:

OOoohhh  :-)    I saw them at GNC the other day but had no idea what they were. I will have to try one!!

Can't wait to hear what you think. Forgot to mention the peanut butter pie flavor is good too.

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I received a letter with my surgery approval from BCBS and it interestingly went into great detail about how my weight loss will result in excess skin and the removal of said skin is considered cosmetic. It specifically stated that bariatric surgery approval should not be considered approval for skin removal. Thought that was an interesting addendum.

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3 hours ago, CurvyMermaid said:

I received a letter with my surgery approval from BCBS and it interestingly went into great detail about how my weight loss will result in excess skin and the removal of said skin is considered cosmetic. It specifically stated that bariatric surgery approval should not be considered approval for skin removal. Thought that was an interesting addendum.

It's all about making a profit and avoiding expenses like this. Let's not kid ourselves. If our actual health and well-being really drove health care approval decisions then WLS would be undertaken by many more people. Mortality in the US is now in large part driven by complications of obesity. Sigh, I will not go down the rant-and-rave path about the idiocy of our system in the US. This is a support Forum. Perhaps some of you saw the recent news articles about Paul X. from the UK who had been the world's largest person and after weight loss had such redundant skin he had to have surgery (done in MA) because it kept getting infected in the folds. 

FYI I thought I had escaped the excess skin issue, perhaps because of my robust exercise regimen, but not so. Not quite 50 lbs down from surgery and my midriff is wrinkled, I have junior (but not major) arm bat wings, and my neck is a bit wrinkly though my face/jaw/neckline have emerged. If I do achieve my goal weight these will clearly become more pronounced. However I AM 62 and no spring chicken ... and my wife is a keeper and I am not in the market and she thinks the new me is just fine (she is a long-suffering soul and perhaps would rephrase this last sentence). My son says the wrinkles add character. So no cosmetic surgery for me. Now I am thinking I will fill up the empty skin in my legs and arms by doing weight training and get my muscle mass (= metabolic rate, heh heh heh) up. I am sure there is a huge trove of postings on the Forum about this that I have not searched yet.... Only mention this because exercise is clearly not a panacea. Some posters a couple of months ago mentioned that recovery from skin reduction was much more difficult than from WLS. 

I am not remembering the exact thread, but there was also a recent posting, to an older thread, regarding some company that charges your insurance company for skin tightening cream and protein shakes and some other stuff. Sounded to me like a total scam to me. To my knowledge there is no cream that really does this. 

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I did some research on body contouring because of the quantity of weight I will be losing and my age - both mean skin removal will be in my future. For surgery approval I also needed to attend one support group meeting, which fell on a date when a plastic surgeon came in to talk about options. Yes, the recovery from what he called a mommy makeover (belly skin removal and breast lift) is much more involved - going home with drains and hunched walking, with recovery as much as 6 weeks. He ballparked an estimate of $10,000 out-of-pocket and if you have evidence of treatment-resistant rashes or hernia, insurance may kick in for some of the costs. I have already started to save funds for this purpose as there are some on this forum that have paid upwards of $40k for belly, arms, thighs, etc.

I asked the surgeon if there was anything that could be done PRIOR to body contouring to 1) minimize skin needing removal and 2) increase success and healing after surgery. He flat out said No. Basically the damage is done, the elastin is gone, so while you might be able to build muscle underneath, which could help healing post-surgery, the only true cure for excess skin is surgery, just as you suspected @BurgundyBoy. I did read an article about body brushing, which is just as it sounds, which helps stimulate blood flow to tissue, and was cited as a way to increase recovery post-surgery. They tried to extend this result to skin tightening but their data did not support this. Side note: The surgeon said he will not do a consultation on someone who is less than a year out from surgery and pefers 2 years.

I also was reading about compression garments that can help in the interim. In fact, a close friend I was talking with about my upcoming surgery said a recent Biggest Loser contestant was a spokeswoman (I think?) for a company that makes compression garments. They aren't as tight as Spanx but are designed for bariatric patients. Something to look into if the excess skin becomes problematic.

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On 6/7/2017 at 0:29 PM, Phoenix97 said:

Thank you so much for your comments! OMG Michael!!!!!!!!!!! Thank you - gave me a lot of information. I am sorry it took me so long to respond. I had a HUGE response then my phone reloaded the page and boop - gone!  I had my dietitian visit yesterday. And you guys are SO right. I am nowhere near ready. I do not understand portions I have NO idea what kind of and how much protein to eat.  I would regain the weight back because ALL of my eating is HEAD HUNGER!!!  

My head hunger and portion control is my problem. Shoot - in this 6 months if I can get control of that, I may not even need the surgery. I NEVER eat when I am hungry. EVER. I never get a chance to GET hungry.  I am going to lurk around on this forum and find the area that talks about head hunger and see what input I can get. I cannot find a trigger at all. It is almost as if it is a fleeting, yet very demanding  - GO EAT- and then - bo, bip,  boop, I toddle off to the break room at work or kitchen at home - mindlessly-  with 500+ calories in the form of a "protein" (in reality CANDY) bar and some package of overly salted (mmmm...salt) nuts. "Healthy" snacks in the break room. Yeah, right.   I just threw out all of the impulse foods at home. Last night when my first GO EAT hit - I was PISSED. Hahahaha!!!

@Phoenix97 I just happened to re-read your post. We are both head hunger slaves. "My head hunger and portion control is my problem." Could have written these words. The number of times I have realized that I just ate 500 calories for no good reason ... it's a big number. 

Did buy a scale and measure everything now. Quite sobering. and, when I get the urge to eat mindlessly... I have a lo-cal lemon drop now. 8 calories. Way better than a half-cup of sunflower seeds or 2-3 ounces of high-fat cheese. It's still something in my mouth so the oral impulse is satisfied. The habit of eating is strong but am hoping this replacement (a lemon drop) is still perceived by my body as an adequate reward for the impulse. 

(Alternatively: I'm not able to really stop putting things in my mouth right now, so am hoping that deception, cunning, and trickery will fool my impulsive self. Those seem to work for a lot of others :rolleyes:, so am taking the giant step of lo-cal lemon drops as my very brave and bold foray into the Dark Side of impulse eating control). 

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