Jenni K.
Here's My Story...
October 17, 2006 - PCP Meria Aulds in Decatur, TX referred me to Dr. Michael Green in Ft Worth for WLS surgery and for a nuclear stress test with a cardiologist. I have diabetis, high bp, trigycerides & cholesterol and a family history of diabetis and heart disease.
November 1, 2006 - Had stress test and ultrasound as previous EKG showed some trouble. Everything AOK after results came back. Advised to quit smoking - first time a doctor actually told me to do this in over 15 years and after sitting in his waiting room with folks at least twice my age, and wanting WLS I am finally listening.
November 7, 2006 - No longer a smoker!
February 3, 2006 - Saw surgeon - Dr. Michael Green in Ft Worth. His assistant, Brandi will be setting me up with various pre-op appts and he thinks I am a good candidate for RNY.
February 21, 2006 - Had sleep study done for apnea. What an experience. Great bed though:) I know I snore like crazy, but not aware of an apnea problem.
February 27, 2006 - Saw psychologist Dr. Jane Counts. Like her a lot. She has had lap band. Uses cpap also and suggested that she never felt better since. Now I sort of hope that I do have it so I too can have much more energy:)
March 1, 2006 - Tonight went to one of Dr. Green's two mandatory seminar sessions. I was dreading it a bit because I have been to one other previously (as well as a consult with another surgeon ~2yrs prior.) I am glad I went because I learned a lot from it. I am realizing more and more how much I don't know and how important it is that I learn more! Was able to talk to former patients (they have lost from 200+ to 55lbs.)
March 3, 2006 - Went to see PCP and catch her up on everything. She wants sleep study results and will get me appt with gastroenterologist closer to home and hopefully one who can perform the endo procedure sooner than April 11. She will write letter of medical necessity and send to Dr. Green. Also spoke with Sonya in Dr. Green's office today about insurance procedures etc. Brandi will compile info and send packet to insurance for approval. They didn't have sleep study results yet.
March 10, 2006 - Well a few things happened today. I was finally able to get the referral from my PCP's office to a general surgeon for the endoscopy that my WLS surgeon wants done. This will be closer to home and completed sooner that the Dr I was scheduled to see. Also my sleep study results are in and they want me to come back in next Wed to get the results in person by a sleep specialist. Seems silly to me - just tell me over the phone what the results are and what we need to do from here. Arghhhhh!
So on Monday I see the nutritionist and Tuesday I see the sleep specialist. On Mon 3/20 I see the cardiologist for his support/letter and Tues I see the endoscopy surgeon for the 1st time and the procedure should be done the following week. Then I'm through with all the prep work.
Next I'll have to haggle with the WLS's assistant to get my paperwork in. I can see it coming already. His practice is very busy and it seems to me a little too busy for great customer service from his office staff. A problem many doctors seem to have. Not the employee's fault - it's the docs responsibiity. Aw well, now I'm off on a tangent. Can't help it - it is so frustrating!
Here I am about a year ago, December 2005.
Letter of Medical Necessity
I thought I would post a copy of the letter I sent to Insurance. I wish I could give credit to the person that I got it from, but I didn't record it then and can't remember it now. My apologies!
BlueCross BlueShield
TRS ActiveCare
Re: Jenni Keith
Group No.: 085000
Identification No.: ISD847781684
Request for Pre-approval for Gastric Bypass
Note: I meet both Milliman and Robertson and U.S. Federal Guidelines:
1. Milliman and Robertson Guidelines for the Gastric Surgery for Clinically Severe Obesity 15 CPT-4: 43847
AND
2. U.S. Federal Clinical Practice Guidelines for the Treatment of Obesity set down in National Institutes of Health Consensus Conference. Released June 17, 1998, the Federal guidelines on obesity were by the National Heart, Lung, and Blood Institute (NHLBI), in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
Dear Sir or Madam:
I am writing to request pre-approval for gastric bypass surgery.
I am 5 ft 4 inches tall and I weigh 270 pounds. My body mass index is 46.3. The body mass index is calculated by dividing a person's weight in kilograms by their height in meters squared. When a man's BMI is over 27.8, or woman's exceeds 27.3, that person is considered obese. The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI near 27, moderate obesity at a BMI between 27–30, severe obesity at 30–35, to very severe obesity for patients with a BMI of 40 or greater 1 2 3. Therefore, I am classified as being very severely obese. The annual number of deaths in America attributable to obesity has been estimated to be 300,000 deaths per year4 5.
I ask for your pre-approval for this surgery. I will detail the issues of medical necessity. I am having significant adverse symptoms from my obesity.
I have sleep apnea. Sleep apnea — the stoppage of breathing during sleep — is common in the clinically severe obese. The health effects of this condition may be severe. It has been estimated that up to 50 percent of sleep apnea patients have high blood pressure. Risk for heart attack and stroke also increase in those with sleep apnea. People with sleep apnea often feel very sleepy during the day and their concentration and daytime performance suffers. The consequences include depression, irritability, sexual dysfunction, learning and memory difficulties, and falling asleep while at work, on the phone, or driving. This condition has a high mortality rate, and is a life-threatening problem. People are usually cured of sleep apnea by this surgery and the permanent weight loss it brings.
I am diabetic. In addition to being a morbid and lethal disease, diabetes has been shown to be very expensive to treat. Rubin et. al. in a study in 1992 showed that yearly health care expenditures for confirmed diabetics ($11,157) were more than four times greater than for nondiabetics. In 1992, diabetics constituted 4.5% of the U.S. population but accounted for 14.6% of total U.S. health care expenditures ($105 billion). Confirmed diabetics constituted 3.1% of the U.S. population but accounted for 11.9% of total U.S. health care expenditures ($85 billion). Health care expenditures for people with diabetes constituted about one in seven health care dollars spent in 1992. (Diabetes in America, 2nd Edition, The National Institutes of Diabetes and Digestive and Kidney Diseases, 1995, NIH publication number 95-1468.) Health care insurers should take note of these findings. Gastric Bypass has been shown to cure diabetes and thus it is cost effective for insurers to pay for surgery to cure diabetes and prevent its complications. Nearly 80 percent of patients with NIDDM are obese.
I also suffer from high blood pressure. Essential hypertension, the progressive elevation of blood pressure, is much more common in obese persons, and leads to development of heart disease, and damage to the blood vessels throughout the body, causing susceptibility to strokes, kidney damage, and hardening of the arteries. If hypertension is not under control, many complications can occur as a direct result of continued high blood pressure. Sixty percent of hypertensive people are obese. The weight loss attained by gastric bypass surgery will cure hypertension.
Also, I have hypercholesterolemia (high cholesterol). When there is too much cholesterol in one's blood, the excess can become trapped in the walls of one's arteries. By building up there, the cholesterol helps to cause hardening of the arteries or atherosclerosis. And atherosclerosis causes most heart attacks. How? The cholesterol buildup narrows the arteries that supply blood to the heart, slowing or even blocking the flow of blood to the heart. So, the heart gets less oxygen than it needs. This weakens the heart muscle, and chest pain (angina) may occur. If a blood clot forms in the narrowed artery, a heart attack (myocardial infarction) or even death can result.
I am depressed. Seriously overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, sneers and remarks from strangers. They often experience discrimination at work, and cannot enjoy theatre seats, or a ride in a bus or airliner. It is no wonder that anxiety and depression might accompany years of suffering from the effects of a genetic condition — one which skinny people all believe should be controlled easily by will power. I suffer from depression and I am on Cymbalta and Trazadone to treat it.
Coronary artery disease is another problem caused by clinically severe obesity. Severely obese persons are approximately 6 times as likely to develop heart disease as those who are normal-weighted. Coronary disease is pre-disposed by increased levels of blood fats, and the metabolic effects of obesity. Increased load on the heart leads to early development of congestive heart failure. Severely obese persons are 40 times as likely to suffer sudden death, in many cases due to cardiac rhythm disturbances.
I have chronic skin problems. I am in a constant battle with yeast infections and chronic rashes in the folds of my body. The obesity causes these skin folds so that skin rubs on skin and the moisture trapped in those creases causes the infections and rashes.
I have made many attempts to lose weight, including:
• Weight Watchers
• Jenny Craig
• NutraSystem
• Herbal Life
• Atkins diet
• Gym memberships
• ...and many of the over-the-counter diet plans and diet medications.
I have included exercise with all weight-loss attempts. I can lose some weight, but then I gain it all back and more. There is not one study that shows that dieting brings permanent weight loss. The National Institutes of Health, in 1991 and 1992 consensus statements, rebutted conventional diets for morbid obesity, and pointed to this important fact: Diets alone cannot be successful for the morbidly obese.
Obesity has been shown to directly increase health care costs. In an article in the March 9, 1998, issue of the Archives of Internal Medicine, 17,118 members of the Kaiser Permenente Medical Care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMIs under 30. For patients with BMIs greater than 30, the study also showed increases in health care costs related to diabetes and hypertension.
Americans spend an additional $33 billion dollars annually on weight-reduction products and services, including diet foods, products, and programs. Most of these expenditures, as is evidenced in my case, are not effective. Rather it can be expected that I will continue to gain weight over the ensuing years and add to this present list of obesity associated illnesses.
Seriously obese persons suffer inability to qualify for many types of employment, and discrimination in employment opportunities, as well. They tend to have higher rates of unemployment, and a lower socioeconomic status. Ignorant persons often make rude and disparaging comments, and there is a general societal belief that obesity is a consequence of a lack of self-discipline, or moral weakness. Many severely obese persons find it preferable to avoid social interactions or public places, choosing to limit their own freedom, rather than suffer embarrassment.
I need this surgery for health reasons, as you can see. I ask that you pre-approve this surgery so that I can become a healthy, productive person once again. Thank you very much for your consideration.
Sincerely,
Jenni Keith
Reference Sources:
1. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Institute of Medicine, National Academy of Sciences. 1995; 50-51.
2. Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Increasing prevalence of overweight among US adults. Journal of the American Medical Association. 1994; 272:205-211.
3. Troiano, R.P., Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Overweight prevalence and trends for children and adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991. Archives of Pediatrics and Adolescent Medicine,1995; 149:1085-1091.
4. Daily dietary fat and total food-energy intakes: Third National Health and Nutrition Examination Survey, Phase I, 1988-1991. MMWR Morbidity and Mortality Weekly Report. 1994; 43:116-117, 123-125.
5. Weight control: What works and why. Medical Essay. Mayo Foundation for Medical Education and Research, 1994.
April 25, 2006
It has been a long time since I've posted and much has happened, but really it seems as though not much important has taken place because I still don't have insurance approval. I'll have to catch up my profile, but for now I just wanted to post the latest.
BCBS Activecare 2 had responded to Dr Green's first letter with a request for more information. Psych report, compliance statement, proof of morbid obesity for five years, and 12 months FAILED medically supervised diet. The first three were not a problem to send, it just took a while to get the medical records, but the diet. Yikes! So frustrating that they actually want to see that you failed - and isn't it obvious I have failed in dieting my whole life.
Anyway, Brandy said they sometimes will take records from Weight Watchers and other programs, so I dug out whatever I could find from weight watchers and they sent everything in.
Yesterday I called Brandy and she confirmed they had sent all the information that was requested and then I called BC and was told that my paperwork was "in review." After pressing her for details on what that exactly meant, the bottom line is that it went to review last Friday, April 21, and will take approx. 3 weeks to hear from them. I marked on my calendar ~2 weeks (May 5) to call them again and check on things.
The waiting is killing me. I actually am planning on getting a denial letter and having to appeal, but I just want it to happen so I can continue on and hopefully get approval and surgery before the next school year begins in August.
I also used my new CPAP machine for the first time last night and things actually went quite well. I didn't wake up during the night at all and woke up feeling quite refreshed:) Pretty good I'd say for the first night with all that equipment hangin' off my head!
May 3, 2006
I'm approved!!! I can't really believe it. I received the letter yesterday and wasn't even sure it was really an approval because of all the disclaimers they put in the letter. I confirmed with BCBS and the Dr's office and sure enough I'm approved and have a surgery date scheduled for May 25!!
I still have to get the endoscopy done, but that is scheduled as well. I spoke to my sisters last night and told them for the first time about having the surgery. They were very supportive and Sandra will come up to help me when the date approaches and will stay for as long as I need her. That is wonderful to hear!
Big news from her too. She's marrying an Englishman and moving to Europe. Yikes!! The last thing I would expect to hear from her, but then again, surprises are more the norm for Sandra:) Luv ya' Sissy!!
It has been a long time and quite a journey since I updated my profile. I had lap rny on 5/25/06. Today is July 3 and I'm 30 lbs down. Whoohoo!
The surgery went well and I traveled home the following day as expected. Both of my sisters came up for my surgery but left the day after I came home. They sure meant well, but as far as helping me, they left when I could have really used some support. My husband is supportive, but not always real helpful. I pretty much feel like I'm on my own in this journey and the boards are the best support I have. Until just the last few days I haven't even wanted to get on the boards. Just felt like I needed the time to adjust - all by myself.
The first night home was horrendous. I was in pain, uncomfortable, couldn't sleep and threw up all night long. The next morning I had some broth and began to feel better except for major gas. Every day was better and better. Resting and sleeping in my recliner worked better than the bed. It just kept pressure off my tummy. After the first week I really began to feel better and could sleep in bed. Even went out to get my nails and toes down!
After two weeks, I felt pretty well recovered and was just getting used to all the changes. I'm still adjusting after 6 weeks. When I began to eat regular foods I had this phenomenon that I just now figured out. I feel like such an idiot. I thought I could eat anything. I have never thrown up since the first night home, but when something doesn't agree with me I can tell when it is on its way out. Rumbling tummy, diahrrea, gas, etc. Nasty!
The phenomenon I mentioned was that when I would eat certain things and they would hit my pouch I would get tremendous hunger pains - at least that is what it feels like and that is what I thought. A few days it dawned on me - what a dip! - what this really means is what I'm eating is hurting my pouch! It feels like what hunger pains always felt like in the past, so it took my brain a while to realize it is my pouch telling me - whoa....that's not going down so well.
It happens with all the things that are typically hard to digest - meats, salad, carbohydrates, etc. I feel so much better now that I have a handle on what is working and not.
I had trouble with vitamins until just recently. I never wanted to take the flinstones w/iron because I just felt like there were better vits than that, but I haven't found any w/iron that are as easy as the chewable flinstones so rather than not take them, I'm sticking to my chewable flinstones for now.
I finally found a liquid bcomplex that goes under my tounge for 30 seconds and then down the hatch. It isn't quite up to a B50, but for now it is the best, easiest thing I can find. I'm working up to doubling the dosage which will get me the numbers I need.
I have a great liquid calcium citrate supplement that I get at Costco which tastes good and goes down well.
My issues now are getting enough water in and exercising. I've always had a hard time with exercising, so that doesn't surprise me, but water I haven't usually had a problem with. I'm trying...
I live in TX and it is hotter than hades this summer, as usual, so even walking is a pain. I do better when I belong to a gym, but currently live in the boonies and joining a gym just isn't feasible. Now I'm trying some DVDs and hoping that will help.
It's a process and I'm still working on improving my compliance in all areas. I still have those days when I think - what have I done! But I'm off all of my diabetis medications already and one bp pill, and have lost 30 lbs so far. I know I'm on the right track and this is the best thing I've ever done!
Interests:
Computers & Internet
Dogs
Teaching
Adoption
Parenting
Movies
Scrapbooks
Teachers
WLS in your 40's
Click here to see interests of other ObesityHelp members.
Surgeon Info:
Surgeon: Michael Green, Jr. M.D.
Insurer Info:
Blue Cross Blue Shield, TRS ActiveCare 2
Surprise! Two days after I spoke with them on the phone, they mailed an approval letter. I received it May 2 and didn't really know if it was an approval or not. It was a bit confusing because of the disclaimers they put in the letter (which apparently is standard). But I now know it is a true approval!!!! Yea!!! ******************* Requested more information and now in review which should take ~3 weeks to receive a decision. I expect denial since one of the things they requested was 12 months of a FAILED medically supervised diet. Dr. Green's office sent them my records of weight watchers and the other info they requested and I started an "official" medically supervised diet this month. It should be painfully obvious that I have failed at dieting all my life. Will update when I hear ~May 12, 2006.
