New Here And ... Very Upset!

[Seannie 42]

Hello everyone!

I hate that this is my first post, but well, I just don't know what to do! I been reading and reading all of these wonderful posts .. getting encouraged and now... Bam!

I promise not to make this long. I went to my first seminar at Emory Johns Creek hospital here in Georgia just the other day. I was so encouraged! It's an American Board of Bariatrics hospital of excellence. The Chief of Staff/director of bariatrics was there and talked about the surgery... etc.. It was GREAT!

I immediately came home, and started looking at my BCBS policy and don't you know it says that surgery of any kind for weight loss was not covered! I was not to be deterred! I call them directly and gave them the CPT codes.... NOT COVERED!! I then asked for a direct link to the policy so that I could review it myself and when I did, I found a little blurb... take a look:

Exclusions:

Exercise, diet or weight loss programs, surgical procedures or other treatments, nutritional evaluations, food supplements, or providers or facilities providing such programs, surgical procedures, treatments, evaluations, or supplements, regardless of the reason for such programs, surgical procedures, treatments, evaluations or supplements.This exclusion does not apply to charges described in Appendix A: Other Covered Services, Metabolic Disorders.

Under Appendix A - it says:

Investigational or Experimental Procedures or Treatment

· Investigational or experimental procedures and treatment, only if all the following criteria are met:

The Physician must certify that accepted medical procedures have proven to be ineffective in the treatment of the diagnosed condition and that the condition, if not treated through investigational or experimental means, would be life threatening. Accepted medical procedures are those treatment modalities that meet the definition of Medical Necessity.

I was happy because I thought.. maybe, just maybe, this is it!! I could maybe find coverage here. But, I sent the policy with all the verbiage to the Bariatric Coordinator at the hospital and she says that she reviewed this with another person and it appears that there is not coverage because under Metabolic Disorders there is no mention of obesity surgery being covered.... ???? WTH...

Am I looking at this the wrong way? isn't a metabolic disorder something like hypertension, sleep apnea, pre-diabetic?? I have all of these.. Looking for any help and words of encouragement. I feel like crying and really trying hard not to!

Seannie

[andersonlj 32]

Sorry to hear about your insurance. I ran into the same problem with my insurance as they would not pay for my surgery either. I saved and put money away until I could afford the surgery. I checked and the price here in the US was around $30,000. I was depressed and knew that I could never afford that. However my brother who lives in California had a friend that went to Tijuana, Mexico and had a gastric sleeve for about $5,000. Now this was a goal that I could possibly attain. I knew that I had to do something and finally I did go and have my surgery. I had surgery on Dec 11, 2011 and I have so far lost 27 pounds and have had no problems. I was very impressed with Dr F Garcia and Hospital MI. They were all wonderful and I could not have had a better experience. You can look at his info at Alighterme.com I hope that this gives you some hope. Never give up on your dream as it will be worth it in the end. Any other questions please let me know.

[Caliblonde 25]

I'm so sorry to hear that you're having difficulty getting the surgery covered through insurance. I think under the policy with the metabolic disorders the only one that might qualify would be the pre-diabetes. The other things are just as serious but they are co-morbidities not metabolic disorders. I would talk to your doctor about the diabetes to see if there is some way to get things covered on the basis of diabetes. I wish you the best!!!

[SouthernSleever 236]

I might be wrong but I think that's the same wording used to say you have to try other programs which are supported by your doctor (ww, adkins) before we will do surgery on you. Press on! PRESS ON!

[Seannie 42]

Thanks you guys! I simply LOVE this forum!! after further review, I think I'm going to simulatenously work through the insurance piece. I'm going to work with the bariatric coordinators further and see how to get the process officially started with the insurance company... how to submit my request for the surgery, appeal process etc.. at the same time, I am going to look into the "Mexico" option.. I got myself together and will not be deterred!! the price for self pay here at my hospital is approximately $16,000... if I had it, I'd do it... BUT thank goodness for my mother who said that she would help pay. If I can get this done in Mexico for less money - BUT still have the quality care, than I will consider that..

@ AndersonLJ... can you tell me a little more about your experience. from the time you started with Dr. Garcia? i've heard of that website from other members here and I am going to look into it..

[Amanda 3.0 140]

Some policies simply do not cover this procedure. Until 2011, our policy specifically excluded it, and so last June I was considering a self-pay option when I decided to review the policy one more time. Lo and behold it was covered (with some jumping through hoops first).

I think you can find a self-pay option in the U.S. if you try. See if your surgeon will take the BCBS contracted rate of payment, which is a fraction of the submitted amount, and perhaps see if the hospital will do the same. The contracted rate is more than likely much less than what they are advertising as a cash discount, to my understanding.

[andersonlj 32]

When my insurance turned me down I was very disappointed as you. My brother who lives in California just happened to have a friend that had just returned from having her surgery in Mexico. He gave me her number and I called and spoke to her several times. She told me everything that I asked and told me that she would not hesitate to recommend going to Tijuana for the surgery. I work as a health care professional here in Iowa so I know a little more than the average person and I was still a little nervous about going to Mexico but after talking to Lori all of my fears disappeared. I contacted Alighterme.com and spoke on the phone to Linda who is the coordinator. She was very pleasant and helpful in answering any questions that I had. I told her that I needed to have my lapband removed and was looking to have the sleeve gastrectomy. She told me which doctors were available and told me the cost. Mine was about $1000 more than just the sleeve as they had to do a scope to make sure that everything from the lapband was ok so that they could go ahead and remove it and do the sleeve at the same time. I knew that I had to do something as I have had hypertension and on 2 medications and was borderline diabetic and they were about to start me on medications and also suffered from sleep apnea. At 56 I knew that I would not be around long if I did not change my life. I scheduled my surgery for a Monday and flew to Tijuana on Sunday. The driver picked me up at the airport and took me to the hotel in Tijuana. I spent the night there and the next morning they picked me up and took me to Hospital MI which was about 6-7 blocks from the hotel. I checked in and they started to do the preop testing. The cardiologist actually came in and did my EKG which impressed me. Then I had blood work drawn. Then it was time for me to go for my scope. When I woke up they told me that it was a go and everything look good. About 5:30 on Monday afternoon I headed off to surgery. I do not remember anything until I woke up in recovery. I was taken back to my room and was started on IV antibiotics, something for nausea and a pain med. I can not say that I really had any pain but more discomfort and some slight nausea. On Tuesday morning they told me that I needed to get up and start walking. I thought no way but I did and walked the hall a quite a bit that day. I felt good but tired. On Wednesday they did 3 leak tests to make sure that I had no leaks and when all came back ok I was released Wednesday afternoon and taken back to the hotel. I rested the rest of the day and watched some tv. On Thursday I felt pretty good so I decided to go to the local mall and do a little shopping. They took me to the mall and I walked around for about 2 hours and then began to feel tired so they took me back to the hotel. On Friday morning around 8am they came to the hotel and picked me up and took me to the airport to catch my plane back home to Iowa. I have been doing great and so far have lost 27 pounds. Next week on Friday I am going to Chicago and will get to see Dr Garcia as he is doing a seminar there on Saturday. I am looking forward to seeing him again and to thank him for all of his care and expertise. I will have a few pictures to share when I get back. If you have any other questions please ask. There are several doctors that do surgery there and I am sure they are all good but I did really like Dr Garcia. Any questions please ask as I am sure that I left some things out. best of luck to you and hope that you can possible get your insurance to cover it. I think that the sleeve through Alighterme.com is around $5000. This includes everything except your place ticket.

[Tana_Q 20]

I'm sorry, I know how disappointing that must be. I hope you are able to get them to pay for it but Mexico does seem like a good alternative just in case.

[SouthernSleever 236]

Thanks you guys! I simply LOVE this forum!! after further review, I think I'm going to simulatenously work through the insurance piece. I'm going to work with the bariatric coordinators further and see how to get the process officially started with the insurance company... how to submit my request for the surgery, appeal process etc.. at the same time, I am going to look into the "Mexico" option.. I got myself together and will not be deterred!! the price for self pay here at my hospital is approximately $16,000... if I had it, I'd do it... BUT thank goodness for my mother who said that she would help pay. If I can get this done in Mexico for less money - BUT still have the quality care, than I will consider that.. @ AndersonLJ... can you tell me a little more about your experience. from the time you started with Dr. Garcia? i've heard of that website from other members here and I am going to look into it..

My insurance didn't cover WLS either but let me tell you after my experience with Dr Aceves in Mexico (only 5 minutes across the boarder in a private hospital) I'd send any of my family back to MX even if my insurance did cover it. My friend here in my same town had a Dr do her sleeve in July, I had mine in October. I'm down 120lbs she's down 60 and when we compare stories my hospital was much cleaner and my surgeon much more experienced. I promise if you research Dr Aceves over any other doctor you will go to him hands down.

[PhatGurl80 26]

My insurance doesn't cover anything weight loss related either. Not even a nutritionist. I wa referred to A Lighter Me by a friend who had surgery in Tijuana the year prior. My cost was $5000 and had surgery with Dr. Garcia. It was a great experience and I wrote about it in my blog. Good luck to you.

[mocha 22]

So sorry you're experiencing this. My insurance excluded too. I went to Dr. Morris Washington in Myrtle beach, SC. Cost me $8000. Good luck with your journey.

[shop4jewelry 0]

Mocha...can I discuss Dr. Washington with you? I am considering him, but thought his total surgeries was a little low.

Thank you!

Does anyone else know Dr. Washington, in Myrtle Beach?

[clk 3,519]

My insurance (Tricare) is a royal PITA so I didn't even bother with them once they told me they'd only cover the bypass or band. I'm another one that self-paid and went to Mexico (all the way from Germany!) and used Dr. Aceves. I can't say enough good things about him and you'll only find rave reviews here and on the OH forums. He's fantastic, and I still hope to get my sister and mom back to him one day for their own sleeves.

I think your plan is a good one - keep pushing with insurance until you hit a definite wall, and start thinking about the self-pay option. I had three doctors on my list of potentials, two were stateside and one was Dr. Aceves. I chose the best price for the best care and couldn't be happier. The good news about self-pay? You get to make your surgery date as soon as you have the money, instead of jumping through hoops for nine months!

Best of luck!

~Cheri