A Large Man

6 Month rule, medicaid, Illinois.

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Hello, everyone! I have yet to introduce myself formally, but let me give myself a quick intro before I ask this question, because I'm pretty anxious about this. 

I am 17, 18 here in a few months, I weigh 356 lbs, 5'11. I have some serious mental illness (been under control for about a year now), due to my childhood, and my weight is a result of it. Over the past 2 years I have avoided gaining weight, only going from 330 to 355 in 2 years, which for me isn't much. I put on most of my weight from 12-15 years old. 

So, here is my question about insurance. I got in contact with my local surgeon center that would do this on me when I'm 18 (November 22). They said that I have to do a 6 month program before insurance would approve this. So, here is my question. For the past 7 months, I have been going to my doctor once a month, every month. I have to get medications refilled that are scheduled, and I also go there to talk to him about how my anti psychotics are working. 

Here is the thing: I never have discussed my weight/diet with the nurse (so maybe it's not in the notes?), but every time the doctor would come to see me, I would tell him what I've been eating and my exercise. He gave me an idea of healthy foods to eat and ways to exercise, I have been following them for the past 7 months. I haven't lost any weight, really, but I've still been doing a "6 month program" my doctor made up for me. The issue is, I had not really considered WLS until about 2 months ago, so when we started this "weight loss program" it was kind of informal. Just a friendly conversation between doc and me about my weight and health. I doubt he even put notes down on it. He did, however, say that he would tell the insurance that we were working on my weight the whole 7 months. 

So, will they accept this from my general practitioner? It's not a huge deal, if I have to wait 6 months, I have to wait 6 months, but I really hope I don't. I figured you guys know more than I do, so here I am. 

Thank you. 

Edited by A Large Man

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Welcome! Did the doctor weigh you at all the appointments? If yes, then I think you have a shot at meeting the requirements.

So sorry about the awful childhood. Glad adulthood is around the corner for you, and you can create the life you want. Looking forward to getting to know you here.

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18 minutes ago, Gretta said:

Welcome! Did the doctor weigh you at all the appointments? If yes, then I think you have a shot at meeting the requirements.

So sorry about the awful childhood. Glad adulthood is around the corner for you, and you can create the life you want. Looking forward to getting to know you here.

Not at all of them. I read more about my states health insurance policy: https://www.illinois.gov/hfs/MedicalProviders/MPAC/Pages/BSCriteria.aspx

Quote, "

ix consecutive months of participation in a medically supervised weight loss program within the setting of a pre-surgical multidisciplinary evaluation must be completed within one year before the prior approval request for the bariatric surgery. There is a demonstration of participant responsibility. 6 Patients must demonstrate motivation to comply with proposed post operative treatment, dietary modifications, and participation in long-term follow-up.

Documentation of nutritional assessment and counseling at each visit with at least one visit with a registered dietitian or nutritionist. Dietary history, eating disorder, pre-surgical caloric reduction, dietary behavior modification, and lifelong need for dietary changes must be completed. An opinion for candidacy for the proposed procedure must be offered. "

Maybe I could get some sort of expedition because of the severity of my weight, idk, but it looks like I have to do 6 months of dieting. Makes no sense. I'll do it if I have to, but for f***s sake. If I could stick to a clearly defined diet for 6 months, we wouldn't be here now would we? 

 

Thank you for the kind words as well. I'm really stressed right now over the fact I'll have to waste 6 months, when I had planned on maybe having had the surgery and having recovered by then, so I can go on to college and move on with my life. But no, now it seems I have to put college on hold, as well as other things, all thanks to insurance. 

Edited by A Large Man

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2 hours ago, A Large Man said:

Hello, everyone! I have yet to introduce myself formally, but let me give myself a quick intro before I ask this question, because I'm pretty anxious about this. 

I am 17, 18 here in a few months, I weigh 356 lbs, 5'11. I have some serious mental illness (been under control for about a year now), due to my childhood, and my weight is a result of it. Over the past 2 years I have avoided gaining weight, only going from 330 to 355 in 2 years, which for me isn't much. I put on most of my weight from 12-15 years old. 

So, here is my question about insurance. I got in contact with my local surgeon center that would do this on me when I'm 18 (November 22). They said that I have to do a 6 month program before insurance would approve this. So, here is my question. For the past 7 months, I have been going to my doctor once a month, every month. I have to get medications refilled that are scheduled, and I also go there to talk to him about how my anti psychotics are working. 

Here is the thing: I never have discussed my weight/diet with the nurse (so maybe it's not in the notes?), but every time the doctor would come to see me, I would tell him what I've been eating and my exercise. He gave me an idea of healthy foods to eat and ways to exercise, I have been following them for the past 7 months. I haven't lost any weight, really, but I've still been doing a "6 month program" my doctor made up for me. The issue is, I had not really considered WLS until about 2 months ago, so when we started this "weight loss program" it was kind of informal. Just a friendly conversation between doc and me about my weight and health. I doubt he even put notes down on it. He did, however, say that he would tell the insurance that we were working on my weight the whole 7 months. 

So, will they accept this from my general practitioner? It's not a huge deal, if I have to wait 6 months, I have to wait 6 months, but I really hope I don't. I figured you guys know more than I do, so here I am. 

Thank you. 

Dear @A Large Man , if you discussed what you are eating, your diet, and your exercise, and you followed the advice, then that is a supervised program. If your GP writes a letter to that effect and includes the dates you were seen and has weight information, then most likely it will be acceptable. It sounds like you have been making a good-faith effort and it was a genuine topic of discussion for the two of you. 

Good luck with all of this. If you go forward, be sure to have lots of social support on your side.... you can rely on this site to be helpful to you. You want to make sure your psychological/psychiatric issues are being addressed; that you can do the weight loss surgery diet (high protein, low carbs) without cheating; and consider some exercise. Success is predicted by having support, by having the p/p issues addressed, and not cheating on the diet.

Exercise tends to guarantee good loss and in the long run is important for good health, even if it is not critical to weight loss after surgery. Lots of people lose weight just fine without it.... but you tend to lose a bit more, and will be healthier, if you get exercise. Medical studies show that a person's BMI at the end of things tends to be about 4 points lower with exercise than without exercise, and it is associated with not regaining weight in the long run). 

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6 minutes ago, BurgundyBoy said:

Dear @A Large Man , if you discussed what you are eating, your diet, and your exercise, and you followed the advice, then that is a supervised program. If your GP writes a letter to that effect and includes the dates you were seen and has weight information, then most likely it will be acceptable. It sounds like you have been making a good-faith effort and it was a genuine topic of discussion for the two of you. 

Good luck with all of this. If you go forward, be sure to have lots of social support on your side.... you can rely on this site to be helpful to you. You want to make sure your psychological/psychiatric issues are being addressed; that you can do the weight loss surgery diet (high protein, low carbs) without cheating; and consider some exercise. Success is predicted by having support, by having the p/p issues addressed, and not cheating on the diet.

Exercise tends to guarantee good loss and in the long run is important for good health, even if it is not critical to weight loss after surgery. Lots of people lose weight just fine without it.... but you tend to lose a bit more, and will be healthier, if you get exercise. Medical studies show that a person's BMI at the end of things tends to be about 4 points lower with exercise than without exercise, and it is associated with not regaining weight in the long run). 

I was weighed probably about 3/4th of the time I went. I was going, mostly, because I was fixing my mental issues. I have them undercontrol for the most part now, but my weight was not the primary reason I was going, although it was secondary. That's why I'm worried it may not be "good enough." And I wont' know for a while, either, which is frustrating. 

And thank you, I will make good use of the forums in the mean time.

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4 minutes ago, A Large Man said:

Not at all of them. I read more about my states health insurance policy: https://www.illinois.gov/hfs/MedicalProviders/MPAC/Pages/BSCriteria.aspx

Quote, "

ix consecutive months of participation in a medically supervised weight loss program within the setting of a pre-surgical multidisciplinary evaluation must be completed within one year before the prior approval request for the bariatric surgery. There is a demonstration of participant responsibility. 6 Patients must demonstrate motivation to comply with proposed post operative treatment, dietary modifications, and participation in long-term follow-up.

Documentation of nutritional assessment and counseling at each visit with at least one visit with a registered dietitian or nutritionist. Dietary history, eating disorder, pre-surgical caloric reduction, dietary behavior modification, and lifelong need for dietary changes must be completed. An opinion for candidacy for the proposed procedure must be offered. "

Maybe I could get some sort of expedition because of the severity of my weight, idk, but it looks like I have to do 6 months of dieting. Makes no sense. I'll do it if I have to, but for f***s sake. If I could stick to a clearly defined diet for 6 months, we wouldn't be here now would we? 

 

Thank you for the kind words as well. I'm really stressed right now over the fact I'll have to waste 6 months, when I had planned on maybe having had the surgery and having recovered by then, so I can go on to college and move on with my life. But no, now it seems I have to put college on hold, as well as other things, all thanks to insurance. 

Ah, this is quite detailed. I would huddle with my doc to see what is there and what you  have accomplished, but it sounds like you need to have at least one visit with a dietician or nutritionist. Maybe that could be scheduled soon. 

Don't beat yourself up. Everybody here has been on diets in the past. A lot of people have lost a lot of weight, but then regained it. Diets fail > 99% of the time for even the most iron-willed people. If diets worked, then there wouldn't be so many obese people, right?

There is this concept of a set point, e.g. for me my set point used to be 240 lbs, then was at 280 lbs. I tried to diet very seriously for a year but could not get lower than the 280 mark for any substantial period of time. Your body is very upset if you diet to a weight below your set point and it thinks you are in the midst of a famine or something else that is awful. When on a diet, your metabolic rate goes down - which runs counter to what you want to happen (that is one reason why exercise may help some people, by keeping their metabolic rate up a bit). 

One silver lining in this is that if you do have to wait 6 months, you can get practiced in the weight loss diet thing, figure out what kind of exercise works for you (it has to be something you do!) 

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2 minutes ago, A Large Man said:

I was weighed probably about 3/4th of the time I went. I was going, mostly, because I was fixing my mental issues. I have them undercontrol for the most part now, but my weight was not the primary reason I was going, although it was secondary. That's why I'm worried it may not be "good enough." And I wont' know for a while, either, which is frustrating. 

And thank you, I will make good use of the forums in the mean time.

Learn as much as you can. Reach out to the people here - they will try to be as helpful as possible. This is not a mean-spirited or snarky or competitive site. Everyone is different, everyone has their own path, and no one will try to tell you that you have to achieve some level of loss to be successful.

One of the other nice things is that people who had their surgery 10 years or more ago still read postings and offer their two cents. I think of them as being the Adults on the site who watch over us Newbies. 

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Thanks. I really wish I did not have to do this 6 month diet, because as I said, I am almost 18 and I have plans for college and for other things and now I have to adjust them drasticly. But It is what it is I guess. I will just try and get some good out of it by giving msyelf extra self education and maybe lose a little weight.

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