AreU1096
July 25, 2006
I began my fight five years ago today, and I have finally decided it's time to tell about my journey thus far.
Less than a month before my 30th birthday, I took a good long look in the mirror and realized that I didn't recognize myself anymore, and I hated whoever that person was who was staring back at me. I didn't know what she did with the real me, but I needed to find out. I cried for about 20 minutes while staring at the tears flooding from that person's eyes. (By the way, since none of you know me, I would just like to clarify that I don't cry...EVER). I don't know how long I would have stood there crying, but my TV was on in the living room, and there was a commercial for Bariatric Treatment Centers (now known as Barix Clinics). Without even thinking, I picked up the phone and called them. This was the first in a series of disheartening calls, since they told me straight out that, since my insurance was an HMO, they most likely would not cover the surgery and I would need to fork out about $30,000 if I wanted to live. Hmmm...sounds like some kind of twisted ransom to me.
Of course, she was right, and when I called my insurance company, I was rudely told, "No. We don't cover anything to do with weight loss," and hung up on. Since that was my only insurance option through my employer, I did the next logical thing...I started looking for a new job (new employer).
It took me a couple years of searching, but I eventually landed my ideal job with the State. After years of hearing how, "the State has excellent benefits," I thought I had finally found my answer. I didn't know a whole lot about the different insurance options available, and ended up choosing...you guessed it...another HMO. As soon as I got the paperwork, I quickly scanned it, only to find EXCLUSIONS: ANY WEIGHT LOSS PROGRAMS INCLUDING THOSE FOR MORBID OBESITY. Okay...now what?
I started checking into other options and found Epic. This is a supplemental insurance, which **AHEM** says that it covers bariatric surgery as long as you are morbidly obese. Once again, I thought I had found my pot of gold. I quickly signed up, and once it went into effect, started working toward approval. Hmmm...Nope... they will only cover any excess charges after your primary insurance is done paying. Since my primary insurance wouldn't cover it, neither would they.
Okay...Plan C...or D...I don't even know at this point. During the next open enrollment period, I switched to the State Standard Plan. In the past, this was handled by Blue Cross Blue Shield, but was taken over by WPS in 2006. Before signing up, everything I read indicated that WLS would be covered, as long as it is medically necessary. Okay...so I'm paying 5 times what I was paying for premiums, but as long as it gets approved, I'm willing to pay it! I signed up and got the membership book...quickly paged to the surgery section. OMG...OMG...can it be true? Will they cover it? Not so fast...there are added provisions. I quickly checked through all the requirements. I meet ALL of them except for a trial of a drug such as Orlistat. Resigned to meet all the requirements, I made an appointment with a new physician. I looked up Orlistat in my pharmacy benefits...hmmmm $200 a month...NOT covered by insurance. At this point, what the h@ll...I'll try anything. I had my appointment. My new doctor refused to give me a prescription for Orlistat because **get this** it doesn't work! He then referred me to their new weight loss clinic. Ok, Dr. Nonuthing (not his real name, obviously). Like I haven't been trying anything and everything to lose weight for the last 20 years!
Well...time was a-wasting, so I went, as they say, "doctor shopping" to find one who is willing to acknowledge that no 34-year-old woman should weigh over 300 pounds. The first appointment I could get was 3 months later. Meanwhile, I went ahead on my own and attended a bariatric seminar at UW Health. Oh, yes, I haven't mentioned the periodic calls I've been getting from Faith at Bariatric Treatment Centers. I really did appreciate all of her follow-ups, but in the end I decided that Illinois was too far for me to go to have this surgery when there is a great team right here in Madison. I went to their seminar and they faxed the preapproval to my insurance.
I patiently waited....for....the....letter...DENYING the surgery! WHAT!?!?!? WHAT!?!?!? DOES NOT COMPUTE!!!!!!! Ok, calm down, calm down....read through the letter. They determined that it wasn't medically necessary. HUH?!?!? I didn't get it. I'm intelligent, but I couldn't understand this. SO...I called the RN at the insurance company who made this determination. According to her, the information she received was only about the surgery itself, and the only information about me that was included was that I was 34 years old.
Okay..it was time to regroup and get everything in order. I requested my medical records from my former PCP. Once i got the records, I went through and highlighted all the information the insurance company would need to grant my approval, and I called the RN back just to touch base with her and let her know I was appealing the decision. Just as a side note, I was put on a prescription drug called Metformin, which is for diabetes (which I don't have) three years ago. It supposedly helps some people with PCOS (which I DO have) lose weight. I decided to take my chances and see if my insurance would accept that in place of Orlistat.
I sent my appeal in, and once again patiently waited. The RN called a little over a week later and said she wished she would have had all the information I sent her in the first place, because I definitely meet the requirements. WHAT?!?!? AM I HEARING THIS RIGHT?!?!? I'm approved?!?!?
No so fast. A couple more obstacles. Before official insurance approval, I need to go through a psych eval and a nutrition consult. Okay, I thought, sign me up! Not so fast. UW Health won't schedule these until insurance approval comes through. Okay, at this point, I'm ready just just change my name to CATCH-22. After explaining the situation, the RN from WPS called UW Health, and they called me the same day to schedule the psych eval and the nutrition consult.
I went to both of these appointments, and "the team" decided that I need counseling to deal with some issues from childhood. I'm not happy about this, but I'm open to it, and I view it as just another hurdle. My biggest fear, however, was that I would have to start back at square one with the doctor-supervised weight loss plan, since it's now going on to two years since the last time I met with my PCP for this reason. I called WPS to find out, and the RN assured me that it was "checked off" and I was considered to have completed it. So, as of today, the only thing I still need to do is finish my 6 months of counseling.
