Question:
Someone posted complaining about people who have this surgery and don't need it

On a question about BCBS of IL - one responder said: "TORI DO NOT WASTE YOUR TIME WITH A LAWYER. THE ONLY THING YOU CAN DO IS TO BLAME ALL THE PEOPLE WHO HAD THE SURGERY THAT REALLY DIDN'T NEED THE SURGERY AND WAS TRYING TO FIND A QUICK WEIGHT LOSS SOULUTION." I am truly stunned at this comment, and am posting this here for discussion rather than sending this person a scathing email. How on earth can a person think ANYONE has this surgery and doesn't need it. Or that doctors will do this unnecessarily. I don't think it is right for this poster to take out their own problems on anyone or make such judgements (and I'm not one of those "you can never say anything about anyone else" people) but holy cow. Geez lady don't take it out on everyone else.    — Calleigh Q. (posted on February 6, 2004)


February 6, 2004
Hmmm . . . I must be one of those people she was talking about, because I had a relatively low BMI to start with-- 40, but I was still Morbidly Obese. At the rate I'd been gaining, if I had waited any longer, I would have just gotten larger and larger. For me, I am proud of myself and the path I chose. I had tried "traditional" means of weight loss for years. Every time I lost 17 bs, I gained back 23! I think that's probably the case with most of us. Traditional didn't work for me, this did. I needed it. If I didn't, I wouldn't have considered it, my surgeon wouldn't have performed it and my insurance company wouldn't have paid for it. Now I am getting healthier and happier. I'm on my way to a normal weght, and I have no regrets. I am very sorry for anyone--lightweights and heavyweights--who are having trouble with their insurance company. But it's not fair for anyone to say that anyone who is Morbidly Obese or higher doesn't need the surgery. And that's all I have to say about that! :) Audra, Open RNY 8/7/03. 5'6"/248/165/140
   — jellybean0605

February 6, 2004
I would agree with that poster if she was referring to people who commit fraud to get the surgery - and there are many out there. Those who have hidden weights, worn extra clothes, or deliberately worked to gain weight to get their BMI into the acceptable range. And I've seen posters who have a BMI of 30 who try to get it approved through insurance. I hope no one has found a surgeon willing to perform such a surgery on anyone who doesn't NEED it.
   — Yolanda J.

February 6, 2004
Unfortunately, there are doctors who will do any type surgery whether it is necessary or not and I do know of at least one case of a person who thought it was a quick weight loss solution and then whined forever at how miserably it failed to help her when all she did was stuff down sweets and breads and potatoes all the time. She didn't change anything and the doctor who did her surgery did not require that she have a psych consult or any of the things the rest of us had to go thru. But responding to the quote in the original post, it is not the perogative of Tori or anyone other than the patient and the doctor to determine whether the surgery is necessary. I ONLY weighed 238 pounds when I had the surgery so I had a relatively low BMI too. As a matter of fact, at the time of surgery I was only 98 pounds over a realistic goal for me. But, when I decided to have the surgery I weighed 276, well on my way to 300. However, with that said, I don't believe that there are that many folks around who have the surgery unnecessarily and I definitely don't believe that is the cause insurance companies are so difficult to deal with and deny in lots of cases. In many cases, it is NOT the insurance company, it is the holder of the policy who established the criteria for the policy. If the policy holder negotiates an exclusion, the insurance company will provide a policy that has an exclusion and they will not budge on approvals. But again, with that being said, there are those policy holders that do not ask for an exclusion, the policy does not have an exclusion, and the insurance company continues to deny and deny and jerk people around. Those are the insurance companies that should be sued!!! (sorry to ramble on so)
   —  SCbabe B.

February 6, 2004
Well I guess I am one of the ones she may be referring to also. I have a BMI of 38 and only 80 pounds to lose NOW....but have been higher and trying to keep it from ever happening again. according to the charts, anything over 30 BMI is obese and it should be up to the patient, the doctor and that's all. In this particular arena, I don't think having 100-200 lbs to lose makes you a better candidate or more deserving of the surgery, just someone who waited longer.
   — tealady41

February 6, 2004

   — Robert L.

February 6, 2004
Robert, I am a medical professional and yes, insurance companies do pay for elective surgeries. "elective" does not mean that the person does not need surgery. It means that it is not an emergency or life saving surgery and it can be put off. I had knee surgery a few years ago. My cartilidge was badly torn. My knee was locking up. My doctor said I needed the surgery but i could put it off and have it at a later date. It was considered "elective"
   — Delores S.

February 6, 2004
It's hard to tell who needs it. My BMI was 56. Sure I needed it, but I had NO COMORBIDITIES. Not 1. I know people at 38 BMI who are in worse shape than I was healthwise.
   — mrsmyranow

February 6, 2004
This is a subject that i am very passionate about. First off let me say that the reason that I choose not to tell many people that i was/already had the surgery is because the few people that i did tell had that same opinion. they ALL, and i mean ALL, said that i didn't need it. that i wasn't THAT big. ok, weight wise, maybe i'm not that big, but at 5 foot 2 inches and weighing 255 pounds i had a bmi of 45+. i had chronic back pain, knee pain, diabetes, sleep apnea, gerd, hypertension and chronic fatigue. not to mention the depression and shortness of breath. and to say the truth, hearing that i wasn't that big or that i didn't need the surgery didn't help one bit. in fact, it made the decision to have the surgery even that much easier for me to make. i met all the criteria for my pcp, endocrineologist, surgeon and insurance company. now people see me and can't belive how i look (even though i am only 5 1/2 weeks out). i have lost 40 pounds and have another 75 pounds to go. i cant stress enough how much this has saved my life and that this IS NOT THE EASY WAY OUT/OR SAY THAT "THE ONLY THING YOU CAN DO IS TO BLAME ALL THE PEOPLE WHO HAD THE SURGERY THAT REALLY DIDN'T NEED THE SURGERY AND WAS TRYING TO FIND A QUICK WEIGHT LOSS SOULUTION". this is not the reason why insurance company's choose not to pay for the surgery. some insurance company's choose not to pay for the surgery because it is a very expensive surgery and having a specific written exclusion stating that they WON'T pay for it does help keep premiums down. now, i am not defending the insurance companies, i think that doctors should be making the decisions and the insurance companies should pay for what the doctors deem necessary. i do know first hand about insurance company's that won't pay. my husbands insurance company absolutely will NOT PAY. it is written in the insurance contract. he does belong to a very strong union and this helps with a lot of things, but not this issue in particular. my dh needs the surgery even more that i did, but my insurance payed and his doesn't. i have since added him onto my policy. AND what is quick about this surgery???? many of us have waited a long time (some of us have waited many months or years) to document all of our co-morbidities, see all of the require doctors, lose a prescribed amount of weight and play the waiting game from the insurance company. in no way did i waste my time or anyone elses, or use this surgery as a quick fix. ---JMO keri lap rny 12-29-03 255/215
   — Keri P.

February 6, 2004
I too am a health care professional. Insurance companies do indeed pay for elective sureries. Delores' description is absolutely right. In fact, <b>most</b> surgeries performed are considered "elective". <br> That being said, what my insurance company deems necessary for me has nothing to do with what it deems necessary for someone else. What my insurance company pays for has nothing to do with what another insurance company pays for...beyond the fact that, if they have too many dis-satisfied customers, those customers will go elsewhere.<br> When people are unhappy with their employers coverage, they do have recourse. A few years ago I had a by-pass graft on my left leg. The surgery left me with nerve damage which was very painful. My doctor gave me every pain killer under the sun...working our way up to MS Contin (an oral morphine). I was put on every seizure drug that has ever been approved for nerve pain. Nothing touched the pain. Then a physical therapist tried a TENS unit on my leg. The relief was unbelievable! But, our insurance did not pay for rental of a TENS unit. I called and called, but they told me that my employer had opted for this exclusion in our policy. So, I wrote letters to my Human Resources Director. I got my facts together....I gave him the statistics for people addicted to prescription pain killers and the studies that showed health care professionals are more likely than the non-profession to become addicted to pain killers. I gave them the monthly cost of the medications I had tried, along with the length of time this was expected to heal, based on my nerve conduction studies. The cost would have been significantly lower for them to rent/purchase the TENS unit. This exclusion could not be changed until the next negotiation period, but indeed it WAS changed. <br> There are insurance commissioners in every state in the union, and they are definately on <i>our</i> side. If there is anything that can be done, they will see that it is done. Then, we have private attorneys who we can hire to help us through the hoops some insurance companies would have us jump through. <br> I know that not all surgeons have the same requirements, but, gosh, I had to go through so many physicians, I cannot imagine someone getting this surgery who doesn't need it. I have had two heart attacks, so I needed cardiac clearance. The surgeon wanted me to see a cardiologist at his facility, which I did, but I would not have considered the surgery without MY cardiologist approval. I have breathing problems and had to have pulmonary approval; my pcp's approval; my neurologist's approval; and my pcp wanted me to see the vascular surgeon to see if he would approve; not to even mention the screening tests that were done pre-op.<br> Finally, when I had my surgery, I had gained up to 301 pounds. Years ago, I was thinking about having this surgery at 236 pounds. A definate "lightweight" by many folks here standards, but I was just as miserable emotionally as I was at 300. I wish the surgery had been as advanced then as it is presently. Thirty years ago, there was a much higher complication rate as well as mortality rate than the present day RNY (or other alternatives) carry. I was afraid to have the surgery then because of these complications. I probably would not have developed all the health problems I went on to develop if I had lost weight at age 25 and a much lower weight. I would have been a much happier young adult, and I think many aspects of my life would have been different. I can't imagine why I would be more "deserving" older and larger than I was back then. <br> I'm sorry that the poster of the comment is so bitter and I'm sorry that things didn't go her (his?) way. I hope she will look into ways to overcome the insurance companies denial. I also pray that she will come to learn that it is very difficult for any of us to know another's needs and make a fair judgement about their "worthiness".
   — Linda S.

February 7, 2004
I think the poster who said that the decision for WLS should be a doctor- patient decision is right on target. The individual wanting WLS should examine their motives for surgery with honesty. The doctor should provide guidance and evaluate the patient's comorbidities, ethically. This would happen in a perfect world. ;) Unfortunately, there are people who are jockying to have WLS in order to resolve cosmetic issues, have no co-morbids and have not in earnest given other methods (ie. dieting/exercise) the old "college try." No matter how many times we tell people that this is not an easy way out and not the answer to lazy person's desire to lose weight, some just don't get the message. WLS is the last resort for people who have been there, done that, tried everything else and their health is compromised. When we decide to have WLS, we make a trade- Suffer from the complications of being Morbidly or Super Morbidly Obese or take the associated risks that we will come through the surgery and be healthier people. There is no guarantee either way. Unfortunately, with the soaring popularity of WLS, being brought on by celebrities and the media, it is feeding the appetite of society, and many are fighting to get what they PERCEIVE as the easiest solution, regardless of whether they meet any sort of criteria. So, it would not surprise me, if I learned that there are doctors who are doing this surgery on anybody, regardless of their weight, bmi or co-morbids in order to turn a fast buck as long as the patient can convince the insurance company to cover it or the patient has the financial means to pay out of pocket. Instead of flaming people, we need to put some energy into giving people information instead of insults. Polly
   — Jackie O.

February 7, 2004
If a person has to lie or cheat to qualify for surgery, than one has to question if they really need it? Not long ago, a lady posted upset that three doctor's had told her she did not qualify for the surgery but yet she was still trying to have it done and have her insurance pay for it. Those are the types of cases I'm sure the person responding to you met. Hang around a while and you will see people talking about squatting down when they measure height so they appear shorter, going to the doctor with rolls of quarters, heavy shoes or wearing layers and layers of clothes so they will weigh more, or will ask how they can gain 15-20 pounds so they qualify. I think people here get frustrated because those who do qualify can't have the surgery and there are those who go to extraordinary means just to qualify. It's a controversial subject no matter which side you take.
   — Shayna T.

February 7, 2004
In my opinion these surgeons are out there to make money...and if a person really wants to have the surgery...even if they don't "need" the surgery, there will always be a doctor who will perform it for them. There are multiple factors as to why insurance companies do not want to pay for this type of surgery, but I would not blaim "people who had the surgery that really didn't need the surgery". Just remember the surgeons and bariatric centers out there are the ones who are really promoting this surgery, and they are the ones who are accepting patients who "don't really need the surgery".
   — Kara J.

February 7, 2004
I'm should have used the term "qualified surgery" instead of "elective surgery". However as an insurance professional I think you might have known that. I agree that most if not all surgery is elective as people can refuse an operation on religous grounds and /or permission must be granted to perform any surgery by oneself or immediate faimly member.
   — Robert L.

February 7, 2004
and "unqualified surgery"
   — Robert L.

February 7, 2004
My surgeon reports co morbidities improve dramatically in those with lower BMIs just like it does for super morbids. I think it should be up to the surgeon and patient. I also believe we need some laws mandating coverage for WLS like is in place for mental health care. People shouldnt die because iof a number on a chart. This is my personal opinion only and not of the site
   — bob-haller

February 8, 2004
It may be very harsh but it is true in insurance terms. I know that there are people who may need this surgery but are not ready for it or are for whatever reason unable to comply with the post op regimen. These people and their failures definitely effect the insurance companies desire to approve others who are ready and in serious need. I think that many people see this as an easy quick fix even if they would never admit it. Just look at all the posts from people who are eating like crap anmd can't figure out why they are not losing. The only way to make this attractive to insurance companies is if it cures comorbidities and we are successful at losing our weight. 25,000+ dollars for something that doesn't work is a waste of money in their eyes and really in mine as well. There are surgeon out there for the money as well as the band wagon jumping of those just not ready.
   — Carol S.

February 9, 2004
Unfortunately as others suggested, there are some people out there who will "cheat" the system to qualify for the surgery, while many deserving and fully qualified people are denied by their insurance companies. And there are others who are not "ready" for this life changing surgery who get surgeons to perform it and then fail at it which may cause the insurance companies to one day revisit their policy and approval procedures. We can only get the insurance companies to continue paying for this expensive surgery if we can show the long term benefits for their doing so. But I agree there should be national standards, otherwise where do you draw the line? And just saying its up to the doctor is not a good thing as we all know there are some unscrupulous surgeons who will do anything for a buck. The National Institutes of Health's guidelines for WLS is a BMI above 40 or above 35 with co-morbidities. Unless national standards are adopted for all, these guidelines will continue to erode..from someone who needs to lose 100, to 95 to 90 to 80, then 50 and where is the line drawn?
   — Cindy R.




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