Frustrated

Well, it is January 2008 and I have hit my last road block that is stopping me from getting the surgery.  I found out the the reason my insurance company won't pay for the surgery is that they believe it is too risky and they don't want to take on the risk.  I even sent in an application to the University of Iowa hospital and since my surgery has two (2) exclusions regarding obesity, they won't even put me on the waiting list.  I have been hopeful but now the air is slowly deflating out of my balloon.  I know I could self pay if I could afford it but that is not an option.  I can't try to finance money when I have no extra money.  It is getting harder to walk and breathe for any distance.  My husband now has to help me put on my socks because I can't bend over that far.  I am 38 years old and sitting at 447 and miserable.  I live in Iowa, so traveling is also an issue for long distance.  I know there is no miracle drug out there, because I think I have tried them all.   I have learned that if you think it is too good to be true, it is!  I have cut back on my calorie intake but now since I have a mobility problem, exercise is quite difficult.  I try to do as much as I can.  I even went to the different talk show websites, like Oprah (for example) and told my story but I haven't heard from any of them in over a year.  My insurance is with United Health Care and I even had my HR person contact them, and they won't budge on their decision.  I have went thru 3 levels of appeals with all declines.  I am married but my husband is disabled and can't do alot of part time jobs.  I have two children and I just want to be able to go for a walk with them.  Taking a bath in a bathtub without any aids would make me on cloud 9.  Is there anyone out there that could let a little light in at the end of my tunnel?

For many people with BMI's 50-60+ they get the Vertical Sleeve Gastrectomy (VSG), which is very safe and has the lowest complication rate. Then they lose 150-200 lbs with the VSG and about 18-24 months later, get the second part--the bypass (either RNY or DS). The original DS was devised as a 2 part surgery, because the bypass part is pretty risky. So the Sleeve (mush less risky) is performed first, allowing the pt to lose a good amount of weight which will result in improved health. Then they are healthy enough for the bypass/DS. They started performing the Sleeve as a sole procedure because they were seeing so many pts losing all their weight with just the sleeve and pt's not coming back for the second part. Many find the Sleeve is enough-- and therefore avoiding the risks and complications of the bypass, and the malnutrition issues. But it's good to know you have the option to add the bypass later, if you don't lose it all or can't maintain it.  I'm pretty sure United HealthCare has been covering the VSG (NOT to be confused with the Vertical Banded Gastroplasty, VBG, which is an older, ineffective procedure that isn;t done much anymore). Although they know that it is very safe because the Sleeve has been performed on people with ulcers and cancer for decades, and also for the 2-part DS for many years. So it has a great safety profile. But since no one was tracking it as a single procedure for WEIGHTLOSS til about 4-5 yrs ago, the long term weight loss isn't well documented. There's lots of stories from people *****mained skinny after ulcers/cancer lead to a Sleeve, and people who didn't want the 2nd part of the DS, but stories don't count in research. Only hard data. And although the sustained wt loss data for 4 yrs is showing to be just a little under that of the RNY (and blowing the LapBand out of the water), you really need at least 5 years of data for it to be an approved procedure. The reason I state all this is b/c some insurances still consider the VSG as "experimental" because they don't know the American Society of Bariatric Surgeons is in the process of responding to a petition from hundreds of surgeons to have the VSG listed as an approved surgery. It probably won't be approved for a few more months, and then we will see the insurances starting to cover it as well (depending on how long it takes for them to keep up with things). Many people have gotten the 2-part DS approved through their insurance because they have a good surgeon that can explain to the insurance how safe the first part is, and the second part won't be donr til you are healthier. Like I said, many don;t need the second part, and they can't make you get it , but at your wt it would probabaly be needed to keep off all that wt. And then you can chose the RNY or DS bypass. Okay, now I need clarification, as I re-read your post. Are you saying your insurance won;t cover it FOR YOU because they think YOU are too high risk? Later you mention your "surgery has two exclusions regarding obesity." What do you mean by that? Did you mean your INSURANCE has the exclusions? Insurance exclusions are almost always because the employer is self-funding their health plan, and chose deliberatly to exclude the surgery as a covered benefit.

But you said you went through 3 appeals. Was your surgeon/PCP involved with this? Did they fight for you? Did they propose a safer surgery like the VSG (there are people over 500 lbs getting the VSG all the time)? Perhaps the issue is that the requested surgery is too risky for you, and if you try another procedure you would have success. You still may have to fight the "it's experimental" claim that most insurances have, but people who have the same restriction on their policies are getting it approved all the time. Espec if it's the only safe option for you. A good VSG surgeon can fight the insr on that. Don't give up honey.

Kahlua

To answer your questions, No, they don't think that I am "high risk" but the procedure itself is "high risk".  The particular plan that we have with the company has the two (2) exclusions for any time of obesity coverage.  I know the company that I work for wants the lowest costing plan and of course they go with a medical plan that has many exclusions in it.  I have had several meetings with my HR person.  Yes, my surgeon was involved in the appeals process.  I have all of the documentation that was sent to my insurance company for Underwriting to make a decision.  I honestly have never heard of VSG.  When I called my insurance company myself, I was informed that my plan will not cover any form of surgery that has to do with obesity.

I'm so sorry to hear that. With the reports of WLS saving lives and the recent article about WLS curing 75% of people with diabetes, how can that be "high risk?" I wonder if they would reconsider it if you applied for the 2 part DS (with the first part of the Sleeve being very low risk-- not much more than getting your gallbladder out). I also wonder if you have any legal recourse under ERISA (granted I don't know much about it).

I wonder if people are going to start submitting for approval for WLS to treat their diabetes, and not necessarily for obesity. It'll be interesting how that will play out. You may find people side stepping the "no obesity related surgery" exclusions, if it goes under diabetes.....

I'm not sure if considering a surgery, which is clearly medically necessary, can be considered too "high risk" in general, if it is an excepted med procedure, and you meet med necessity. They can't generalize like that! That's why I thought they were reviewing how risky it would be for you personally, but they can't just not cover it because they think, in general, all WLS is risky.

Usually what happens with the smployer-funded plans is that someone from your company handles the appeals, or an approved 3rd party reveiwer, and that it still boils down to your employers wishes. Insurance plans are supposed to offer all medically nec treatment, but employers who decide to not buy a plan from the insurance co, they can self-fund and cherry-pick what they want to pay. It's really your employer who would be paying for the surgery, and they just pay the insurance comp to manage the plan for them.

I'm hoping Paul or Gary might chime in on this. Something just doesn't sound kosher to me about why you were denied.

In the meantime, my heart goes out to you!

((((BZZYMOM))))

Hugs,

Kahlua

Thank you for your words of advice.  Regarding insurance, you are correct, my employer selects the plan that will cost the least amount of money since my employer pays some of the insurance and I pay the rest.  I even offered to pay extra for a rider to be added and was shot down with a negative answer.  My insurance company says that medically needed is a life and death situation and since I am not laying on my death bed, then my life is not threatened.  Even though I have problems doing the basic daily chores, it is not good enough.  I have went to another surgeon's seminar and he said to make sure insurance covers the procedure before he even begins to look at me.  My PCP has written several letters of recommendations to the insurance Underwriting department but again their answer was "no".  I know I have to meet a deductible first before my insurance will pay anything, but they still won't cover the surgery.  I have sleep apnea, I am now taking a water pill to lower my blood pressure and then I take some medication for PMS.  I do not have diabetes or any thyroid problems...my PCP has tested me for those conditions.  I feel like a mime in a box that can't find a way out.