WLS Pre-Ins. Approval Update

Got a call back today from Amy at Dr. Gupta’s office.  She said that she is still waiting for the psych eval, but that is understandable as Dr. Hess did say that it could take up to two weeks.  I’m just staying on top of it all to make sure that it doesn’t land on someone’s desk among a big stack of papers…. not that Amy is that way…. just a precaution.  Amy said that as soon as she gets that eval from Dr. Hess then she sends it over to Dr. Stote, who is also a psych, to review Dr. Hess’s eval and come to a final conclusion as to whether or not I need any further evaluations.  I am wondering if they are doing this so that they can say that they got a second opinion before sending it off to the insurance company and if UHC had any questions about it then they can tell them that two psych doctors agreed with the eval.  Just a thought on that.

Amy also told me that she has not gotten my recorded weights from Ellen at my PCP’s office for the years of 2003, 2004, and 2005.  I called Ellen and left her a message to call me back.  I know they have records with these in there.

Sooo… that’s about it for right now on this topic.

~Tammy~

September 26, 2008

Today’s Date: September 26, 2008

Okay I guess I should do some updating. Goodness. I cannot believe that the month of September is almost over! This entry will probably be fairly long. I’m going to have to stop waiting so long between writings.

On September 9th, 2008 I headed up to St. Vincent Bariatric Center of Excellence, in Carmel, for my first support group meeting that they have for patients that are going through this surgery. As I was getting ready to pull out of the driveway M got off the late bus. She asked where I was going. I told her and asked if she wanted to go to. She said she did and …. LOL… she is such a hoot. So at this meeting one of the surgeon’s decided to come in and talk (I guess it isn’t something that always happens), Dr. Evanson is his name. I was actually really glad that he did because it gave M an opportunity to hear everything and to ask questions, which she did ask a few. I learned more about the procedure, the before and after as well. Very informative! M was stuck on Dr. Evanson’s physical appearance and decided to tell him (out of ear shot to myself… and kind of on a dare) that she didn’t know what it was but she was curious how it is that he and her PCP were both hot. LOL. I have since found out from writing about her little stint on a forum board that many have also had this very sentiment. Oh, there is not a membership fee or extra cost to go to these support group meetings. At the end of the meeting the Nutritionist who was actually the sessions leader for that day gave us a attendance verification sheet that we need to send to our particular surgeon so that they have it on file and know that we had gone. I am going to fax these all in at once later on. I honestly do not know if Dr. Gupta requires these or not. I know it was a suggestion that one go to them but I don’t recall her specifically saying how many one had to go to prior to surgery. So, I’ll go to as many as I can before surgery and then make sure that she has the attendance verification sheets before hand.

On Sept. 12th Dr. Hess called me back, after I left her a message, and explained to me how she does her psych evals for this surgery. She usually meets with the individual for one hour (she has done enough of these that she knows what is needed and doesn’t have to have a great deal of time) then will write up her evaluation, which she says can take anywhere from 2 to 3 weeks before the surgeon’s office has that document on their desk. Sometimes a person needs to come back for further evaluation, but usually it is just the one appointment.

So, I go ahead and I keep my appointment for Dr. Hess to do the psych eval. I’d rather pay a $15 co-payment than pay $115, no offense to the other Doctors’ that do have that. I actually think it is cool that they offer that option for people that are doing self-pay in order to do this surgery. Anyway, I go to see Dr. Hess on September 13th. The appointment was for 10:30 am that Saturday morning. I got lost! Finding 103rd Street off of Spring Mill Road was not a problem. The problem was finding the building within that complex there. The sign is very small and it is NOT in the same location that is shown on mapquest…. I dislike mapquest sometimes. So since I did not have my cell phone on me, the battery was dead so I left it at home, I pulled into some hotel near there and called her office to find out exactly which building it is in. I left a half hour before the appointment to get there and hind up being a half hour late. All I could think at that point was, “Great! I’m going to fail this psych eval because I am not being very punctual today!” But, Dr. Hess did part of the session and we set up a second date to do another ½ hour session on a different date and time.

Second appointment with Dr. Hess was on September 19th at 12:30 pm. It was only suppose to be a half hour appointment but I think we hinded up talking for about an hour. It went well, or at least I believe it did. She told me that she saw absolutely no reason for me to not have this surgery done or for me to wait to have it done. She said that she is confident that I will do just fine in managing it and that I have proven time and time again, in her opinion, that I can overcome major changes with no problem and do a great job in disciplining myself to keep going. All of which is true. So the next step…. She is going to prepare the written eval that is needed and will fax that over to Amy at Dr. Gupta’s office. Dr. Hess said that if I call Dr. Gupta’s office, or they call me, and tell me that they have not received the eval from her anytime after two weeks and still do not have it after a month then to call her and she will refax it over to them. She said that she has had it happen that evals get stuck on someone’s desk among a mountain of other papers and so she just wanted me to know.

On September 24th, I went to my second support group meeting at 3:30 pm again at the St. Vincent Carmel facility in the same conference room as the Sept. 9th meeting (through Entrance 3 then take elevator up to 2nd floor and go to suite: 255). At this meeting one of the “center’s” Nurse Practitioner’s, Linda, was the facilitator. There were about 4 or 5 people at that meeting that have already gone through this surgery, but most were in the beginning phases like myself or have already received their approval from the insurance company and just waiting for a surgery date. I wish I could say that I learned a great deal from that particular session, but I didn’t. Now, don’t get me wrong here… just because I didn’t learn much at that session does not mean that the information that I did learn from it won’t be added to in other sessions thus making the “whole” of the information learned significant and valuable. I am sure that will be the case. I, again, got my sheet from Linda and have added that to my binder to be faxed over to Dr. Gupta at a later time.

Today…. Today I am going to call over to the insurance company, yet again, to see if anything has changed, policy related, on the requirements for the approval process and coverage if approval is received. I will also be calling Amy over at Dr. Gupta’s office to see if by chance she has already received that document from Dr. Hess. I also want to see if she can give me an idea as to how far out Dr. Gupta is scheduling her surgeries at this time. I will most likely have to leave Amy a message as she never seems to answer her phone. She does try to return phone calls within 24 hours but since today is Friday she most likely will not return my phone call until Monday.

Today is also another interesting marked moment. Today is the first day that I am attempting to cut out caffeine. Although I am still a little fuzzy as to “why” it is so important in this process to not have caffeine…. It is only because I haven’t done that much research on it yet. I know that there are health benefits to not having caffeine, but the flip side is I have heard in the past that there are health benefits to having caffeine also. Either way… I am going to cut out the caffeine. Carbonated beverages are the other thing that I am going to have to cut out and I have been working on that already. I think I have it down now where I could stop drinking any soda and be fine with it. Switching to decaf coffee and tea… I don’t think that will be an issue… like I said today is the first day for going without it and I am just going to quit caffeine beverages cold turkey just like I did smoking. Interestingly this morning when I had my coffee (Folgers, decaf smooth) I really liked it. Right now I am drinking Lipton’s decaf tea (iced) and I have it sweetened with Splenda and it is really good. Now, whether or not I will even be able to tolerate Splenda after this surgery is still up in the air (meaning that I won’t know until after the surgery if it will be tolerated).

Well… that’s my current update. Told you it may hind up being a little lengthy.

~Tammy~

September 03, 2008

Today’s Date: September 03, 2008

Well… Amy from Dr. Gupta’s office called me back with the answer that I had yesterday about needing to get the paperwork from my PCP’s office to send to the Insurance company myself as well about the requirement for the 6 month physician assisted diet. I am really stoked now. (Figure of speech!!) I found out from her that according to the information that she had obtained from UHC (and the department that she deals with all the time within their company) I do not need to send them any documentation from my PCP’s office myself. The only things that needs to be sent in are my letter of medical necessity, my psych eval results and a record showing my weight in the last 5 years.  Amy said that if I can get this back to her soon then the chances of me having a response in less than a month from the insurance company about my approval is very good. This is very, very good news.  However, the probability of this actually happening are VERY slim.  No big deal…. I’ll take it one step at a time.  I’m just glad that I do not have to mail any medical records to UHC myself.  Course I do know that it is possible that this very minimal bits of information can be sent in and they (UHC) may hind up wanting more information…. which would go out in an appeal.  BUT… I’m going to keep my chin up and take it one step at a time…. preparing for the “what may could happen” at the same time… just in case.

Tammy

September 02, 2008

Today’s Date: September 02, 2008

Telephone call to UHC to check again on the criteria that will be needed by them for the board approval. Reason: to see about need for 6 month “medical weight loss summary” from my PCP.

Representative talked to: Karin

Also have them checked that Dr. Christine Gupta was on my in-network list of approved doctors. And she is in-network. Karin told me that on 8-18 Dr. Gupta’s office called and checked up on benefits and that they did confirm with her office that I am covered for the procedure under our schedule of benefits and that the criteria for our benefits is that it be a “medical necessity”. Karin said that as far as the 6-month “medical weight loss summary” goes that isn’t a part of their requirement under our plan, and she did go through and look to see if she could find under UHC’s system a definition specifically for “medical necessity”, for which she did not find anything.  Karin also double checked in their system and was able to see diagnosis in past of pre-diabetes, Type II, as well as the PCOS. I inquired about where it should be that I am to send the fax with the required medical records from My PCP’s office to them and she gave me: 1-801-567-5498 (FAX) as UHC’s Central Line Fax to the area district office that handles Indiana. She did advise that I make certain that the Fax Cover Sheet is written to the ATTN: REVIEW DEPARTMENT so that it will go to the correct place and have less chance of getting lost within the system. She said to call back after 2 days of sending the fax to make sure that it has been received within their system and has been forwarded to the correct review department.

Sooooooo… next on my list of things to do…. telephone call to Dr. Gupta’s office and talk to them and see if they still want to do about the lack of “Physician medical weight loss” for 6 months…. As the sheet they gave me to give to my PCP’s office has that on there. Is it still needed from my PCP and if I don’t have that with him is it required by them specifically even though it is not a requirement from the standpoint of my insurance policy. Will going through such a 6-month weight loss attempt prevent me from being qualified for the surgery since I am right on the line with my BMI? Uuuugggghhhh… Guess I should just call her office and ask. Right after I check my E-mail and call my boss. (30 minutes later.) Okay, so I am done with my boss… for the moment. I love my job! (And, no I am not meaning that sarcastically… I truly do love my job.) Now I am going to call Dr. Gupta’s office and since it is just a little after 1:00 someone should be back from lunch and there. So I get “one” of the “Heather’s” on the phone and she transfers me to “Amy” who I then leave a message for on her voice mail. Oooooookay! So, just to wait until she calls back, may be tomorrow. Sooo… in the mean time I still need to call over to my PCP’s office to talk to Ellen about the fax number that they gave to us for them to send stuff to them for. A very important piece of information as that will help to curve some of that red-tape…. Not to mention help to keep people from “losing” bits and pieces of my medical records. (sigh) Yet another thing done for the day in relation to this. It is now 1:30 and I think I am going to switch gears for the day. I am going to put this stuff away and move on to doing some more of my homework / mid-terms that is due by ohhhhhh tonight at mid-night. (Don’t ask if I am done with all that… I’m getting there. I’ll just leave it at that.)

Tammy