Saturday, January 12, 2013

Getting Approved

Obviously, the path between deciding on surgical intervention and actually going under the knife isn't overnight. The surgeon's office and program have certain requirements you must meet, and if you are having the procedure paid for through insurance, they have their own separate requirements too. All insurance companies and programs do things differently; this is what mine required, and how long it took.

During my initial visit with my surgeon, Dr. Murayama, we went over the three types of surgery that he performs (RNY, Sleeve, LapBand) and what would work best for my situation and goals. I had originally wanted the LapBand since it didn't involve rearranging my anatomy and was reversal, if need be. Dr. M informed me that, due to my starting and goal weights, it would not provide the results I wanted/needed to be healthy, and further told me that RNY was my best option. He gave me a comprehensive overview of what is done during surgery, and how it helps with the weight loss. I also received a thick binder of information and plenty of orders - blood work, EKG, pulmonary functions testing, and an abdominal ultrasound. Filled with motivation and hope, I was ready to go over to the outpatient lab at the same location and get the first blood tests out of the way. Dr. M recommended that I first call my insurance company to make sure it was a covered benefit - I hadn't even considered that it might not be!

So I called my insurance company (Blue Cross Personal Choice) and after discovering that it was a covered benefit, inquired as to their requirements to qualify. Here is what they told me:
- 3 months of "Medical Weight Management"
- 5 years documented attempts of weight loss attempts and results
- BMI >35 with at least 2 co-morbidities (such as sleep apnea or PCOS, both of which I have) or BMI >40
- I would need a letter from my PCP stating that I was medically stable for weight loss surgery
- Of course, meet all requirements of my surgeon's office

They also said that each office visit would be my usual $20 copay, and each day in the hospital would be a copay of $75, up to 5 days. Past that, it would be covered 100%.

Additional requirements of my surgeon's office:
- 2 hour information session (free)
- Psychiatric screening ($275, not billable to insurance)
- Pre-op nutrition class 2 weeks before surgery ($200, not billable to insurance)

Now, this may sound like a lot of hoops to jump through. There were times, especially near the end of the process when I was waiting around for a certain amount of time to pass until the next appointment, when I got incredibly frustrated with it. However, the whole idea is not only to make sure you have the best physical chance for success, but to ensure that you have a good expectation of life after surgery including dietary, supplement and exercise requirements and restrictions, emotional issues that may arise, and the progression of events and checkpoints to expect, thereby also making sure you are mentally and emotionally prepared through education.

The information session was exactly what it sounds like - informative. Those who didn't already have one got the thick binder, plus a folder with various web links, book suggestions, and a BMI calculator wheel. The presenter, one of the dietitians, went over the 3 types of surgery that are offered through the Penn program including advantages and disadvantages, why you might want to choose one over the others, risks, success stories, an overview of post-op life and requirements, and some of the more common issues that arise. He was thorough, well-spoken, engaging, and gave helpful answers to questions.

Medical Weight Management (MWM) sessions are monthly check-in appointments through the surgeon's office, but can also be completed with your choice of doctor. One of the reasons that I chose to go through my surgeon's office is that doctors who do not work directly with the program can sometimes not document the visits adequately or correctly, resulting in delays or possible insurance denial on first submission. At the session you have your vital signs taken and are weighed, then visit with a dietician and RN who are part of the program. You also fill out a paper with what you ate the previous day, all medications and supplements being taken, and your exercise level and frequency. Again, in addition to providing documentation for the insurance company, this makes sure you are beginning to modify your lifestyle to give a greater chance of success post-op. As for the 5 year history my PCP, Dr. Carol Fleischman, is in the same network which has a shared electronic medical record system, so in conjunction with the mountain of paperwork that I had to fill out for the psych screening, Dr. M's admin Marissa was able to compile and present a comprehensive history.

The psych screening was a bit intimidating. Before hand, you were required to fill out 2 documents. One was a bubble sheet questionnaire regarding your current and past mental state, outlook, and other similar things. The other was a booklet of about 20 pages. The instructions said to allow about 2 hours to fill it out. "Sure", I thought, "maybe for the average citizen, but I'm a paperwork master". They were NOT kidding. It was full of dense, in-depth questions about your eating and exercise habits, a survey of your past weight loss attempts and the results, family information that I had to call my parents and siblings in order to complete, and personal questions that required introspection and reflection. I did the bulk of it all at once, and left the more difficult or lengthy sections for later. I'm so glad I started it well ahead of time, because it took between 90 minutes-2 hours to do in total. At the psych screening I also had a MWM appointment scheduled. The 2 documents were taken back for review in the beginning so that the psychiatrist could look over them and identify any potential issues or areas for discussion. We went into his office after MWM and talked for about an hour. He was very personable, and started by going through the documents to make sure that I hadn't left anything out, and to clarify some responses. It ended up being painless and stress-free, and was purely to make sure that I had thought about surgery in terms of how it would change my life emotionally and mentally, and to make sure I had a strong support system in place. I passed. Good thing, too, because if you don't pass you have to wait at least 1 month before trying again, and frequently are required to get counseling! It's all for your safety, but what a pain that would have been!

As I neared the end of my required appointments and tests, I was instructed to call my PCP to request the very short but all important letter. I had already had my timeline to surgery delayed a month, since my first appointment with the surgeon did not end up qualifying as MWM since the usual topics weren't discussed as in-depth as they should have been. When I heard back from my PCP she told me that, due to my elevated liver enzymes on the blood tests from a couple months ago, I would need to re-test to make sure they had normalized. They hadn't. This meant I had to see a gastroenterologist (liver specialist) to get to the bottom of what was making the levels so out-of-whack.

The AST # was way above the expected range (15-41), but could have pointed to several things.
The ALT # was also way above expected range (14-54) but was more troubling, as it is an indicator of liver damage.
As you can see in the above graph, both enzymes have plummeted back to near the expected ranges since surgery.

Getting the first appointment was a nightmare; I called 4 different offices in the Penn network, but none had anything less than a month out. Just when I was starting to think that I was going to get delayed indefinitely, my PCP triaged my case over to Dr. Ranjeeta Bahirwani. I was thrilled to find yet another amazing doctor in my care network, and felt in great hands within minutes of my first appointment. Over the next six weeks I had vial upon vial of blood drawn, went over the same history information umpteen times, and even had to get a liver biopsy (through the jugular vein, no less!). In the end, nothing was found to be wrong. The levels were just super high for no good reason. Even with the changes to my diet that I had been making, they persisted. Luckily, Dr. Bahirwani saw no reason to delay surgery and forwarded the same recommendation to the surgeon's office and my PCP.

Dr. Fleischmann was prompt in writing the letter stating that I was "medically stable for bariatric surgery", and I received notice from Marissa at Dr. M's office on November 15 that my records were ready to submit to insurance. The next day they went to Penn's internal insurance submission office, and went to Blue Cross on Monday the 19th. Marissa had told me that my insurance company usually took about a week to respond, but that with Thanksgiving being in the middle of that week, it might take up to 2 weeks. I was thrilled when, 2 days later on the 21st, she called to say they had just received approval! As most of the rest of the office staff had gone home for the holiday already, it wasn't until the following Tuesday that my surgery and pre-op class were actually scheduled, but this was starting to feel like it could actually happen. What great news to bring to my family at Thanksgiving!

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