Opening this up for discussion, not judgement or criticism.

One of the things I've witnessed here that has always made me raise my eyebrow a bit is people's questions about -- and others' willingness to help -- "beat the system", so to speak. I haven't seen the topic come up in a while, but when I first joined it was fairly common for someone to want advice on how to qualify for the lap-band, even though they don't qualify. And there was a lot of advice given about putting sand in clothes, weights in shoes, forcing down a gallon of Water before being weighed, etc.

Opening this up for discussion - in general - is it ok to "nudge" the system this way? Is there anything wrong with doing it? What's the line between what's "ok" to nudge, and what isn't?

I used to scoff at people who got banded at around 70 lbs over weight (I was 140 over when I got banded). Now that I am about 70-75 overweight, if I lost my band, I would want another one. If someone had told me at the weight that I am now, that I was going to gain another 70 lbs, but I could stop it if I had a band installed, I'd probably be all over it. Fortunately, in talking to people who 'only' had 70 lbs to lose, I never expressed my thoughts at the time, and came to my senses, lol.

There are probably plenty of people out there who've not really 'tried' to lose weight and turned to surgery, but then there are lots of people who have tried everything and then turned to surgery. I wouldn't know by looking at someone. And nothing by looking at someone 70 lbs overweight tells me that they haven't been struggling just as hard as I have and just want the struggle to go away (at least the hopeless part of the struggle).

Of course none of that answers whether I'd fool insurance. I didn't have insurance when I was banded, and my BMI was 45, so even if I had, I'm not sure it would have been a problem. If I was 10 or so lbs shy of the limit, I'd probably just go gain the weight 'naturally', but then, I'm not sure that's any better morally than putting quarters in my pockets, you know?

Alexandra,

you wrote...

"It is never a matter of 5 lbs or 1 BMI point that keeps medical necessity from being established. People just don't get declined for this sort of reason if they truly need the surgery."

I feel I do need the surgery. I have no comorbidities. The first time I submitted my claim to insurance I was 39 BMI. I was denied. A short time later, I was 40.5 BMI and appealed. The denial was reversed and I got approval. I still have no comorbidities. But I feel truly certain that diabetes is coming for me, if I don't do this.

Perfect Post Sarah!!! :rant:

Please read my post again. I did not condemn the woman who needed to lose 68 lbs. I said I didn't know her story. Looking at her it didn't appear that she had weight to lose. I was only wondering about the choice. Did she do everything before taking such a drastic step, or did she do the surgery as a first attempt? I worry that this surgery is getting so popular that we will be having it for not the right reasons. I have been fat all my life and have suffered with every weight gain, every diet, every lb gained. I am not judgemental about those that have less to lose than I or haven't experienced all the gains and losses. What I was trying to express is that this is a major decision. It shouldn't be taken lightly. I don't think we should put teens through this until other avenues have been tried. To that end, the insurance guidelines are helping, in some cases. There will always be those that can afford it on their on and not need the insurance. There are those that need this surgery to live a healthy life. I can't judge anyone, nor do I want to.

When I was waiting to be wheeled into the operating room, my prep nurse asked me why I was having the surgery that I wasn't big enough to have it. (Judgement...This is exactly why I was not telling people I was having the surgery.!) I told her that I have Osteo-Arthritis and the Orthopedic Doctor told me for every pound I was overweight my knees felt it times seven. She just said OH!

I try not to get involved in controversy but...I am a nurse also. I see all of the injustices perpetrated in the name of our insurance system. The bottom line is all that matters to insurance companies. My insurance excludes WLS ($15000) but they paid $25,000 for my heart cath last Oct that I wouldn't have needed had I not been overweight. I'm not blaming the insurance industry for my weight problems. I did that all by myself. But as for everything else, they are defenseless. Katt

First, what Alexandra said.

Then, no matter how people try to justify their actions, for me, it boils down to this: people either honor the agreements they've made in life or they just want everybody else to honor their agreements. In life, I try to avoid those who don't care for honoring their side of agreements.

Also, the people I most often see (on another board, in particular) willing to "nudge" the facts are those who consistently support politicians who want to give MORE latitude to insurance companies and fewer services to the insured. If people want fully funded health care, they should pay attention to who they're voting for. (We have friends, a doctor and family, in Denmark, who are AMAZED at our low taxes...and WE are amazed that we PAY for stuff they receive as subsidized government services. We can either PAY for medical care in cash or we can PAY higher taxes which will cover that care...nothing is free.)

Further, lots of people with BMI's between 30 and 40 have had LapBand surgery in this country. They just paid for it themselves. And, kind of like Alex said, no one is keeping them from having life-saving surgery, because they are not (yet) in a life-threatened situation. They're just being kept from having their elective surgery for a problem that is NOT (yet) life-threatening paid for by a policy that doesn't cover "elective surgery for a problem that is NOT (yet) life-threatening."

And I went to Mexico and paid cash for the band...before anyone asks. (The DS was done in CA and insurcance covered it.)

Sooo..

in general - is it ok to "nudge" the system this way?

No, it's insurance fraud and the people doing it are actually criminals.

Is there anything wrong with doing it?

Yes, it's insurance fraud and that's a crime.

What's the line between what's "ok" to nudge, and what isn't?

If your weight fluctuates right on the borderline even on days you're NOT being weighed by the doctor..by all means, skip the diuretic that morning. Or eat Fritos the night before. And if you gain eight pounds every month with PMS, by all means, schedule your appointment for when you're having PMS!! But once you start LYING about your height and putting weights in your clothes, you are commiting a crime and I, for one, wouldn't mind watching you pay for that.

Alexandra,

you wrote...

"It is never a matter of 5 lbs or 1 BMI point that keeps medical necessity from being established. People just don't get declined for this sort of reason if they truly need the surgery."

I feel I do need the surgery. I have no comorbidities. The first time I submitted my claim to insurance I was 39 BMI. I was denied. A short time later, I was 40.5 BMI and appealed. The denial was reversed and I got approval. I still have no comorbidities. But I feel truly certain that diabetes is coming for me, if I don't do this.

Operative words: if they truly need the surgery. YOU may feel that at a BMI of 39 you "need" bariatric surgery, but you were otherwise perfectly healthy. At that BMI, the entire medical establishment agrees that surgery is not routinely indicated for healthy people. And it's those guidelines that the insurance industry uses to make determinations. (Doctors, of course, can and do make other determinations for self-pay patients.) As I said, a line simply must be drawn somewhere, and that's where it's drawn. The line may change in future, as evidence mounts that prevention is more efficient than the vastly more expensive treatments obese people need. But for now, it is where it is.

Maybe you weren't as healthy as you thought, though. If diabetes is indeed in your future, you might have tested now for a pre-diabetic condition and that could have served as a co-morbidity. If you have a family history of diabetes, hypertension, or hypercholestemia, those would also have served. But for the purposes of insurance coverage, perfectly healthy people who happen to have BMIs of 39 really don't need insurance to cover their surgeries right now. There are other, sicker people in line ahead of them. And that's the way it should be.

Opening this up for discussion, not judgement or criticism.

One of the things I've witnessed here that has always made me raise my eyebrow a bit is people's questions about -- and others' willingness to help -- "beat the system", so to speak. I haven't seen the topic come up in a while, but when I first joined it was fairly common for someone to want advice on how to qualify for the lap-band, even though they don't qualify. And there was a lot of advice given about putting sand in clothes, weights in shoes, forcing down a gallon of Water before being weighed, etc.

Opening this up for discussion - in general - is it ok to "nudge" the system this way? Is there anything wrong with doing it? What's the line between what's "ok" to nudge, and what isn't?

The original thread didn't say anything about insurance. Even if you are self-pay there are guidelines the " U S " doctors are supposed to follow on who qualifies for the surgery. Though there are some doctors who do it cosmetically, there are still guidelines on the 35 BMI with co-mor or 40 without....

So my question is... what do you all think about nudging the system if insurance isn't part of the equation???? I'm not talking about insurance fraud I'm talking about nudging the guidelines of who qualifies for the surgery according to the 'standard US practice and the manufacture recommendations". <o></o>

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Cashley,

You have hit on the point I've been trying to make. This is now big business and I think there are lots of doctors out there that will push the limits. If the patient is self-pay who do they have to justify the surgery to? I am worried that this is now seen as the next best thing to slice bread. Here in Houston they air so many lapband ads that everyone is very much aware of what it is. They are glamourizing it. To me it is the last step in changing a unhealthy lifestyle. I can't seem to do it on my own. Maybe I feel like a failure in that I had to have the surgery and sheer willpower wasn't cutting it for me. I don't know. I just know that if there is a dime to be made, there are plenty out there willing to rake it in.

I had Lasik surgery in 1999. I only knew of one other person who had it done. It was a medical miracle for me. It is less expensive, more common and very much advertised now.

I feel the same way about Lapband. I didn't know anyone who had a Lapband before I got mine. My best friend, my daughter, and several other people I know have now had this procedure. I also believe it to be a medical miracle and it should be advertised and available to everyone who needs or wants it.

i'm not for trying to beat the system per se, but what marimaru said is very true and worthy of more national discussion: isn't it just as "immoral" to go and push your weight up even more just to qualify for WLS? immoral to continue abusing yourself when you know that it's wrong?

i believe so. that's why we need to push to make medicine more preventative, WLS included! lapbands are just as revolutionary and life changing for those who want to reverse a (quite often) yo-yo weight gain at 50 pounds as it is to reverse a 200-pound one.

many people who are within 50-60 pounds of their goal weight are hanging on my their bare knuckles! and if they know themselves and their life-long struggle, that's a PRIME reason to 1) have the surgery and 2) make insurance companies and the FDA understand that stepping in to relieve the pressure, pain, and possible (inevitable??) climb to a higher weight is good medicine.

Cashley, you're right that the opening post didn't mention insurance. I'm sorry, I just assumed that's what Wheetsin was talking about. Oops!!

As far as nudging the "system" to get a band if one isn't MO by AMA's standards, I see it as absolutely no different than any other service that can be purchased. There's nothing "immoral" about having a lot of money and wanting to better oneself surgically, if you can find a doctor who will do it. If one won't, there is always another who will.

If you're self-pay and want to lie to your doctor to "qualify," your doctor equally wants to be lied to, believe me. He's not fooled by a couple of rolls of quarters in the pockets, not really. I imagine Inamed and medical oversight boards are the parties to which he'd have to justify a given procedure, if he were asked, and of course there are always liability issues. But in the end it's a judgment call by the doctor, and they're human.

and i'm not so sure that the gov't guidelines for what constitutes a medical necessity for a band is purely based on scientific research and safeguarding the public's health. i simply don't believe in them like that.

and i'm not so sure that the gov't guidelines for what constitutes a medical necessity for a band is purely based on scientific research and safeguarding the public's health. i simply don't believe in them like that.

I don't think it is based on "safeguarding" the public's health. It's based on risk/benefit analysis, which is why it seems so way off for banding. The years of RNY and other bariatric surgeries are the body of experience they use to calculate such things. It will be several MORE years and MANY more banding patients will have to be studied before any changes are made.

IMO, there should be a huge divide between RNY qualifications and those for banding. The current guidelines don't take into account the exponential difference in risk level. Someday, we can hope, they will.