Readytobeme

Disgusted/ 6 month rule

49 posts in this topic

So, I have been going through a few different weight loss attempts over the last few years. Both were medically supervised. Both were failed attempts so I decided to move forwards with WLS.

Found out that my health insurance requires that I do some type of medically supervised weight loss program for 6 consecutive months in the two years preceding WLS in order to approve me.

My first thought was this was great because I already have my time in for approval and do not have to wait an additional 6 months. FF to today when I stopped by the bariatric doc to get a record of my payments to them. Just to be sure that I had met the criteria for insurance. I went to them a total of 11 months. took a 1 month break after the first 5 then went for 4 more and finally last 2.  I took those breaks just enough to screw myself from meeting the consecutive 6 month rule :(

I am going to call my insurance company in the morning to see if there is any chance that they will accept what I have. I am not holding out much  hope at all though. So disgusted with myself right now.

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My bariatric center told me straight out at the beginning it was 6 straight consecutive months.  Do not skip any months or you will have to start over.  Let's hope your insurance gives you a go ahead!!

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That really sucks...big time!! I seem to be one of the few on the forum that didn't have to go through a six month supervised diet prior to surgery. I just had to meet my surgeon's requirements. I think I would have lost it if I were in your shoes! Maybe you can reason with the insurance company...praying they will give you the green light!!

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Yes. I knew that my insurance requires the 6 consecutive months. I just really thought that I had it covered. Crossing my fingers that insurance will count it. If not it will only tack on a few more months. Trying to stay positive but already having many ups and downs this early into it.

Before the 11 months with bariatrics, I did 9 months with family Dr on Qsymia. So, I did put forth much effort before jumping into surgery. Just hoping that insurance will look at it the same way.

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Thank you, Trish. Maybe they will surprise me. Either way they will not deter me. I will do whatever it takes because i know that I have to.

 

Thanks for the kind words all.

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Just now, Readytobeme said:

Thank you, Trish. Maybe they will surprise me. Either way they will not deter me. I will do whatever it takes because i know that I have to.

 

Thanks for the kind words all.

Stay strong my friend...you'll get there!! If this helps at all (it probably won't, but I'm going to tell you anyway, lol), I was due to have my surgery on March 1st of 2016...yep, last year...but I got derailed with a diagnosis of thyroid cancer. So I had to have that treated before they would do my bariatric surgery. I started this journey in November of 2015, and had WLS on May 17th, 2017. It was a long road getting here, but it was definitely worth the wait!! Don't let anything deter you...this is going to be one of the most important steps you can take to getting healthy and have a longer, happier life! Look at it as a speed bump in the road to WLS. One that may delay your surgery for a bit, but not stop it from happening! 

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I faced an unexpected delay in mine as well. A few days (6 to be exact) before setting my surgery date, my husband died. My surgeon made me wait almost 6 months after that before setting a new date because he didn't want such a big decision made at such a stressful time. I used that time to completely change my lifestyle to the healthier one I'd require after surgery....there were no post surgery shocks for me, plus I lost a lot of weight which made my surgery much safer for me and far easier for the surgeon.

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Just now, Aussie H said:

I faced an unexpected delay in mine as well. A few days (6 to be exact) before setting my surgery date, my husband died. My surgeon made me wait almost 6 months after that before setting a new date because he didn't want such a big decision made at such a stressful time. I used that time to completely change my lifestyle to the healthier one I'd require after surgery....there were no post surgery shocks for me, plus I lost a lot of weight which made my surgery much safer for me and far easier for the surgeon.

(((Hugs))) @Aussie H :wub: I can't think of a sadder thing to have happen...WLS or not. It was probably a good idea to wait under those circumstances. And like you said, you used the time to give yourself the chance at a much safer surgery, and to change to a healthier lifestyle. I can't say I'd be that strong...I'm quite sure I would fallen off the wagon and used that as an excuse to start binging again. You're such a strong person to not only have made it through such a difficult time, but come out on the other side in a better position to have the surgery. You're such a strong person...I truly admire your strength!!

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1 hour ago, Trish1967 said:

Stay strong my friend...you'll get there!! If this helps at all (it probably won't, but I'm going to tell you anyway, lol), I was due to have my surgery on March 1st of 2016...yep, last year...but I got derailed with a diagnosis of thyroid cancer. So I had to have that treated before they would do my bariatric surgery. I started this journey in November of 2015, and had WLS on May 17th, 2017. It was a long road getting here, but it was definitely worth the wait!! Don't let anything deter you...this is going to be one of the most important steps you can take to getting healthy and have a longer, happier life! Look at it as a speed bump in the road to WLS. One that may delay your surgery for a bit, but not stop it from happening! 

 

Oh, no! I am so sorry to hear about the thyroid cancer. I have a friend that had heart trouble. Ended up in ER and having a stent placed due to an artery that was 90% blocked. Because of that happening, they found her thyroid cancer. She was symptom free so who knows when it would have been detected had her heart not given her trouble.

Actually, she is like many of us here when it comes to weight and losing it. Her heart Dr tried to talk her into bariatric surgery. She asked me what I knew about it. I didn't know much about it except that it struck fear in my heart lol

That is exactly when I found this forum. I was trying to find info to share with her about a year and a half ago. I am hoping that once I get through the surgery that she and my eldest sister will find the courage to do this as well.

Thank you for sharing your story. I know that many people out there have it harder than I am for sure. I will just stay focused and be thankful that I even have insurance at all that will help cover it.

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1 hour ago, Aussie H said:

I faced an unexpected delay in mine as well. A few days (6 to be exact) before setting my surgery date, my husband died. My surgeon made me wait almost 6 months after that before setting a new date because he didn't want such a big decision made at such a stressful time. I used that time to completely change my lifestyle to the healthier one I'd require after surgery....there were no post surgery shocks for me, plus I lost a lot of weight which made my surgery much safer for me and far easier for the surgeon.

 

That must have been a very hard time in your life. What strength you have shown to be able to go through with it after losing your husband. Very sad and you do have my deepest sympathy for your loss.

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1 hour ago, Trish1967 said:

(((Hugs))) @Aussie H :wub: I can't think of a sadder thing to have happen...WLS or not. It was probably a good idea to wait under those circumstances. And like you said, you used the time to give yourself the chance at a much safer surgery, and to change to a healthier lifestyle. I can't say I'd be that strong...I'm quite sure I would fallen off the wagon and used that as an excuse to start binging again. You're such a strong person to not only have made it through such a difficult time, but come out on the other side in a better position to have the surgery. You're such a strong person...I truly admire your strength!!

 

I honestly could not agree with your words more.

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That really says alot about the compassion that AussieHs surgeon has as well. Some wopuld have just went for the cold, hard, cash rather than truly looking out for the welfare of the patient.

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1 hour ago, Readytobeme said:

That really says alot about the compassion that AussieHs surgeon has as well. Some wopuld have just went for the cold, hard, cash rather than truly looking out for the welfare of the patient.

While I have nothing but admiration for my surgeon, his pocket was never going to be affected by whether my surgery happened or not. He is a salaried employee in a publically funded hospital. I actually had two surgeons for my revisional surgery, the head of bariatrics and his 2IC. Mine was always going to be a very different and diffult surgery due to my prior very old WLS. I'm actually very lucky that any surgeon would have taken it on, and even luckier it was publically funded, because that meant the surgeons weren't rushed by time pressures so were able to unexpectedly complete my almost 4 hour procedure laprascopically. I was always told to expect it would end up an open procedure. I saw a documentary last night on obesity surgery in Australia and they stated only 10% of weightloss surgeries in Australia are performed in public hospitals, the rest are all privately funded surgeries. I consider myself blessed that my surgeon not only discovered my problem, but was also prepared to fix it..... And for free!!!!!

@Trish, I wasn't strong the whole time. It took me a good 4 months to get my act together and start losing. I would have gained at least 15lb in that 4 months as well.

Edited by Aussie H

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Ok. I wasn't thinking about how different the medical field operates in Australia than it does in the USA. I am glad that it all worked out so well for you in the end though.

 

I may still be able to get away with my actual visits not being 6 consecutive months after all. The wording of my policy gives me hope.

 

requires a history of trial and failure of at least one or more of the following non-surgical measures, supervised, over a least a 6 month consecutive period within the last 2 years prior to the date of surgery:
• Diet / nutrition regimens
• Behavioral modification
• Exercise
Additionally there must be documentation regarding the following:
• The member’s medical and mental health has been assessed showing they are an acceptable candidate for the procedure and able to comply with all post-procedural follow up care and nutrition.
• The member has been made aware of the potential risks and benefits of the procedure.
• The member has been made aware of pre and post-surgical dietary expectations.
Policy

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7 hours ago, Readytobeme said:

 

Thank you for sharing your story. I know that many people out there have it harder than I am for sure. I will just stay focused and be thankful that I even have insurance at all that will help cover it.

If there is one thing I DON'T want you to take away from my post, it's that I'm saying people have it harder than you!! We all have our trials in this journey, and in life. I'm not meaning, in any way, to minimize your frustration with the insurance company or your situation :wub: There will always be someone that has it harder, but that doesn't diminish our stress, frustration or anxiety over our own situation.

I posted about my cancer not so much about the cancer, but the huge delay it made for my WLS. My surgeon discovered through pre op testing that I had a parathyroid tumor (non cancerous). He said it needed to come out prior to WLS because it causes a blood calcium problem that can cause osteoporosis and other health problems. It was only when they did surgery to remove the parathyroid that they diagnosed the cancer. After my second thyroid surgery, on April 6th last year, I then had to wait longer because I needed radioactive iodine treatment (standard for thyca). That was in August. By the time I was done, I couldn't imagine going through another surgery...plus through all of that stress, I had gained back all of the weight I lost pre op (46 pounds, ugh). When I was finally ready to climb back on the wagon this year, lol, in March, I did. Best decision I've ever made in my entire life!! Now I'm 105 pounds down since starting my pre op diet, and 71 pounds down since surgery :) Despite a couple of other bumps in the road, I feel better than I have in years :) 

So I guess what I'm trying to say, in my usual too long and too wordy version is this...it is very frustrating and stressful having unexpected delays while going through this process. But that's why you come here and vent about it!! This group of wonderful people have been so very supportive and caring, and have always been my cheerleaders through all of my difficult times.  We are all here for you too ❤️ 

My hope for you is that the insurance gives you the go ahead, since you've already gone through 11 months total of this, even though you've missed a month here and there. Keep us posted please!! 

I also hope that your friend is doing well with the heart trouble, as well as the thyroid cancer. A good portion of the time, thyroid cancer is diagnosed secondary to other health problems. I'm glad they found hers! Prayers being sent for you both!

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Thank you, Trish. I may have worded things wrong. I meant that I need to keep in mind that people have jumped through much harder hoops than I am/will and made it to the other side just fine. No doubt that I will as well :)

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Just spent the last hour and a half on phone with insurance company. Finally found out that yes, I am going to have to start the 6 month weight loss trials all over again.

Leaving the info here for others that may have the same issue in the future.

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The very best thing about the 6 month supervised diet thing is that it is an opportunity to really focus on changing habits and lifestyle.  Specifically I think there is lots of value in working on alternate coping skills; what will you turn to for comfort when it can no longer be food?  Learning to chew thoroughly, developing the habit of not drinking before, during or after eating.  These are things specific to WLS that are not repeats of what you've already done and will set you up for long-term success.  This is not just another diet, thank God, because none of us have been successful with those lol. 

I understand your frustration, and indeed it is only in hindsight that I realize how much I appreciate that 6 month getting ready period.  Best to you as you begin the journey to your new fabulously healthy life!

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It was 5 months from the day I first saw a surgeon about an umbilical hernia who suggested doing bariatric surgery at the same time because if I didn't lose my excess weight (and keep it off), the hernia surgery was unlikely to remain successful.

Having said that, my programme was pretty intensive and it was made clear that if I missed a meeting, I'd have to start all over again.

I'm glad I had those 5 months.  Along with the psyc. visit, my programme also covered nutrition, goal setting, living well with stress, communication skills and weekly support meetings.  

Truthfully, there is much more to bariatric surgery than just having the surgery and nothing but the bariatric program could have prepared me for the life afterwards.

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My insurance required a 3 month supervised diet. I started the 3 months and during month 3 freaked out and decided "I would try one more time to lose the weight on my own." I gained 10 pounds that month. So, I had to re-start. I was really mad at the time. In hindsight, for me, it was the best thing that could have happened. I spent that 3 months jumping through the rest of the hoops and really working on the head stuff - how and why I allowed myself to get to fat in the first place. (And then lose it and gain it all back plus more.) I spent a lot of time trying to change my relationship with food. I am not someone who believes 'everything happens for a reason' so I certainly don't think that about my re-start (or yours.) Despite my frustrations and anger I chose to use that time to keep working on my food issues and I'm glad I did. Maybe I would have had the same success and outcome 4 years later but maybe not.

 

Hang in there. Yes, 6 months is a long time and after you have surgery, you'll be at goal before you know it. 

 

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I must say that the nurse at the bariatric center tried everything that she could think of to get the time to count. Just so frustrating the way that it worked out. I thought that I had seen my PCP in August for my 6 month check up and to talk to him about bariatric surgery. But, noooooo!!! lol It would be comical if I were not so aggravated about it all. I did my blood work in August but actually saw the Dr on Sept. 2. Had I seen him in August, the 4 months before that going to the bariatric dr would have counted. Just one road block after another it seems.

I am scheduled for my nutrition eval and should be scheduled for psych eval by weeks end. After those and 5 support groups are completed, at least I will be able to meet with the surgeon.

That is another point of stress for me.There are 3 surgeons on the team. The 2 with the most experience (and online reviews) take awhile to get an appointment with. There is another surgeon in the group that has been with them 5 years. I could get in with her much sooner but, unable to find many reviews on her. At this point I don't even know which surgeon I am going to use.

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17 minutes ago, Readytobeme said:

I must say that the nurse at the bariatric center tried everything that she could think of to get the time to count. Just so frustrating the way that it worked out. I thought that I had seen my PCP in August for my 6 month check up and to talk to him about bariatric surgery. But, noooooo!!! lol It would be comical if I were not so aggravated about it all. I did my blood work in August but actually saw the Dr on Sept. 2. Had I seen him in August, the 4 months before that going to the bariatric dr would have counted. Just one road block after another it seems.

I am scheduled for my nutrition eval and should be scheduled for psych eval by weeks end. After those and 5 support groups are completed, at least I will be able to meet with the surgeon.

That is another point of stress for me.There are 3 surgeons on the team. The 2 with the most experience (and online reviews) take awhile to get an appointment with. There is another surgeon in the group that has been with them 5 years. I could get in with her much sooner but, unable to find many reviews on her. At this point I don't even know which surgeon I am going to use.

Protest to the medical monitor at your insurance company. This is unreasonable. 

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Just now, BurgundyBoy said:

Protest to the medical monitor at your insurance company. This is unreasonable. 

I think so as well. The CSR at my insurance company didn't even want to give me info this morning. They said that the doctors office has to call preauthorization dept just to find out. I got forceful with the CSR and she finally told me that if it says consecutive, it has to be consecutive.

I told the CNA that I deal with at my surgeons office that I am willing to appeal if it got denied for this issue. She told me that it will be best just to start over again. That the 6 months would fly by before I knew it.

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5 hours ago, Readytobeme said:

I think so as well. The CSR at my insurance company didn't even want to give me info this morning. They said that the doctors office has to call preauthorization dept just to find out. I got forceful with the CSR and she finally told me that if it says consecutive, it has to be consecutive.

I told the CNA that I deal with at my surgeons office that I am willing to appeal if it got denied for this issue. She told me that it will be best just to start over again. That the 6 months would fly by before I knew it.

Press on. Threaten to go to newspapers and better busiNess about heartless stupid company. State you will have lawyer in 24 hours too. Be unspeakably polite.

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Plus check if your doc received blood work results, = a form of supervision. If they say it doesnt, ask why there are rules for timely review of lab results unless it is to monitor you.

Press on.

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